SHORT JALKS 



WITH 



Young Mothers 

Charles Gilmore Kerley,M.D. 






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Sbort XEalfcs 
Witb l^oung /Ifcotbers 

ON THE MANAGEMENT OF INFANTS 
AND YOUNG CHILDREN 



Charles Gilmore Kerley, M.D. 
i 

Professor of Diseases of Children, New York Polyclinic Medical Schooj 

and Hospital ; Attending Physician to the New York Infant Asylum ; 

Assistant Attending Physician to the Babies' Hospital, New 

York ; Consulting Physician, New York Home for Crippled 

and Destitute Children; Consulting Pediatrist, Greenwich 

Hospital; Consulting Physician, Savilla Home, N. Y. 



SECOND EDITION, REVISED AND ENLARGED 



ILLUSTRATED 



G. P. PUTNAM'S- SONS 

NEW YORK & LONDON 
Gbe IKnfckerbocfcer press 

1909 



\p 



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Copyright, 1901 

BY 

CHARLES GILMORE KERLEY 
Copyright, 1909 

BY 

CHARLES GILMORE KERLEY 
(For Revised Edition) 



Cl. A '-t'i 47 85 
AUJ 18 1909 



^tbe IKnfcfcerbocfter jptess, «ew Boris 



TO 
L. EMMETT HOLT, M.D. 

Clinical Professor of Diseases of Children in the College of Physicians 
and Surgeons (Columbia University) New York 

THIS WORK IS INSCRIBED 

IN RECOGNITION OF HIS HIGH PROFESSIONAL ATTAINMENTS AND 

ENTHUSIASM IN PROMOTING THE STUDY OF DISEASES 

OF CHILDREN, AND IN GRATEFUL APPRECIATION 

OF MANY ACTS OF KINDNESS 



PREFACE TO SECOND EDITION 

THIS book was originally prepared with the 
view of aiding young mothers in the care 
and rearing of their children. In the second 
edition, new subject matter has been added, to- 
gether with additions to the text, with the 
hope of further extending its field of usefulness. 



PREFACE 

THE aim of this book is to help the 
young mother to a closer acquaint- 
ance with and a more intelligent apprecia- 
tion of the nature and demands of the 
little life entrusted to her care. 

In its preparation the author has kept 
in mind and has endeavored to answer 
the personal questions of many thought- 
ful young mothers 1 The better-class young 
mother of the present day is not content 
with the meagre information possessed by 
her mother and grandmother. 

Suggestions relating to medical treat- 
ment are intentionally avoided. A mother 
should know all the details of the child's 
feeding, clothing, bathing, and airing, and 
what to do in an emergency. She should 
also be able to recognize symptoms of 
illness and appreciate their significance. 
She is not supposed to be skilled in the 
use of drugs. 



INDEX 



Adenoids 






i37 


Appetite ..... 


143 


Artificial— bottle — feeding 


54 


Preparation of food 


59 


Milk and cream feeding . 


61 


Top-milk feeding . 


65 


Baskets for early exercise 


316 


Baths ...... 


117 


The cold douche 


118 


Tub-baths for fever 


120 


Basin bathing for fever . 


120 


Bathing for comfort in hot weather 


120 


Mustard bath 


12 1 


Brine bath 




121 


Soda bath 






121 


Bran bath 






122 


Starch bath 






122 


Hot bath 






122 


Bed-wetting 






284 


Bites of animals 






248 


Bites of insects 






. 248 


Boils . 






245 


Bronchitis 






171 


Burns 






246 



IX 



Index 



Care of the breasts and nipples 

Care of the genitals 

Painful micturition, circumcision 

Chicken-pox 

Children's parties 

Cleanliness . 

Clothing to be provided 

Cold hands and feet 

Cold in the head (coryza) 

Colic .... 

Condensed milk 

Constipation. 

Management in the breast-fed 
Management in the bottle-fed 
Management in older children 

Convulsions .... 

Cough ..... 
Chronic cough 

Croup — catarrhal, diphtheritic 

Crying .... 

Cuts, bruises, and sprains 

Dangers from flies and mosquitoes 
Dentition .... 

The breast-fed 

The well-managed bottle-fed 

The badly fed 
Diet after the sixth year 
Diet during illness 

The art of feeding in illness 



Index 



XI 



Disinfection after contagious diseases — 


fumigation .... 


201 


Diphtheria ..... 


. 191 


Drug-giving .... 


. 312 


Earache .... 


122 


Eczema . 


. 231 


The strait- jacket 


• 233 


The mask 


• 235 


Enlarged tonsils . 


140 


Excitement . . 


296 


Feeding after the first year 


■ 73 


Fever ...... 


. 249 


Fissures of the anus 


. 244 


Food formulas .... 


- 3 2 4 


Beef-juice 


• 3 2 4 


Beef, mutton, and chicken brotl 


1 ■ 3 2 5 


Scraped beef . 


• 3 2 5 


Egg-water 


• 3 2 S 


Oatmeal jelly 


• 3 2 S 


Wheat jelly and barley jelly 


• 3 2 5 


Barley-water . 


. 326 


Rice-water 


. 326 


Dextrinized barley-water 


. 326 


Oatmeal-water 


. 326 


Imperial granum- water . 


. 326 


Whey .... 


. 326 


Junket 


• 3 2 7 


Foreign bodies in the ear and nose 


. 306 



Xll 



Index 



Foreign bodies swallowed 

German measles . 
Glands. 

Acute enlargement of the glands of the 

neck . 

Chronic enlargement of the glands of 
the neck 
Grippe 

Habits 

Ear-pulling . 

The "pacifier" habit 

Masturbation . 
Habitual vomiting 
Head lice — pediculi capitis 
Height in inches from birth to sixth year 
Hives .... 
How the child should be fed 
How to examine the throat 
How to lift the baby 

Indoor airing 
Intertrigo 

Kissing 

Malaria 

Malnutrition and marasmus 
Maternal nursing . 

The diet 

The bowel function 



Index 



xm 



Maternal Nursing — Continued 

Air and exercise . . . .24 

Regularity in nursing . . -25 

Signs of successful nursing . . 26 

Signs of unsuccessful nursing . . 27 

Signs of insufficient nursing . . 32 

Management of abnormal milk condi- 
tions . . . . 32 

Mixed feeding . . . -35 

Maternal conditions under which nurs- 
ing is forbidden . . . -36 
Conditions which may temporarily 
produce an unfavorable effect upon 
the breast-milk, but not necessitate 
the discontinuance of nursing . 36 
Conditions which call for temporary 

discontinuance of nursing . . 38 

Care of the nipples . . . .39 

Giving of water .... 40 

Frequency of nursings ... 40 
Measles . . . . . 195 

Milk-crust . . . . . .238 

Milk for travelling . . . . -99 

Milk in infants' breasts . . .141 

Mumps ; . . . . .186 

Night terrors . . . . .318 

Nose-bleed . . . . . .291 

Nursery-maids . . . . .134 

Patent medicines . . . . -309 



XIV 



Index 



Peptonized milk . 

Immediate process . 

Cell process . 

Partially peptonized milk 

Completely peptonized milk 
Pneumonia .... 
Premature and congenitally weak: i 
Prickly heat 

Retention of urine 

Rheumatism 

Rickets .... 

Scales for vreighing 
Scarlet fever. 
Scurvy 

Sick-room for contagious diseases — 
rantine 
Disinfectant drugs . 
Sleep ..... 
Sprue and thrush 
Sterilization and pasteurization of milk 
Stomatitis, or sore mouth 



. :ea 



aon 



Prev 
Red: 
dea 



1110 COlC 



food 



Index 






Temperature, and how to take it 
The baby-basket and its contents 
The care of the eyes 
The contagious diseases 
The daily outing . 
The delicate child 

Normal development 

Abnormal development 

Management . 

Regular weighings necessary 

Feeding delicate infants . 

Diet after the first year . 

Baths .... 

Fresh air 

Sleep .... 

The nursery . 

Influence of climate 

Clothing 

As to the nature of the clothing 

Exercise 

Midday nap . 

Entertainment 

Education 
The exercise pen . 
The first duty to the child 
The hair .... 
The normal throat 
The nursery .... 
The nursing-bottle and nipple 



XVI 



Index 



The proprietary foods 

The uses of proprietary dried-milk 
foods . 

Proprietary foods to which fresh cows 
milk is added 

The proprietary beef foods 
The selection of milk 
The skin in health 
The teeth .... 

The care of the teeth 

The permanent teeth 
The trained nurse 
The weight of the well baby . 
The well baby 
The wet-nurse 
Tonsillitis 
Tuberculosis 

Vaccination . 
Vomiting 

Weaning 

Care of breasts during weaning 
When to send for the doctor . 
Worms 

Round -worms 

Thread-worms 

Tape-worms . 
Whooping-cough . 



ILLUSTRATIONS 



Baby-Basket .... 


PAGE 

2 


Nipple-Shield .... 


. 4 6 


English Breast-Pump 


47 


Nursing Bottle and Nipple 


• 54 


The Chapin Dipper 


59 


One pint Graduate 


60 


Freeman Pasteurizer with Bottle Racl 




Removed .... 


72 


The Throat Examination 


154 


Cold Compress .... 


169 


The Holt Croup-Kettle . 


i75 


Crib Prepared for Steam Inhalation . 


176 


The Electrotherm . 


224 


The Breck Feeder . 


227 


Strait-Jacket . . . . 


233 


Strait-Jacket in Position 


234 



xviii Illustrations 



PAGE 



Mask Pattern . . . . 235 

Hood in Position . . . . .236 

The Bulb Syringe . . . .281 

Basket for Early Exercise . . .317 

Scoop and Platform Scales for Weighing . 320 
Exercise Pen . . . . .322 



SHORT TALKS 
WITH YOUNG MOTHERS 



SHORT TALKS 
WITH YOUNG MOTHERS 



THE BABY-BASKET AND ITS CONTENTS 
(See Fig. i.) 

A BASKET in which all the toilet necessi- 
ties for the baby may be kept together 
will be found a great convenience when the 
time for their use arrives. 

To be provided are: 

A good-sized pin-cushion and pins. 

Puff-box and puff. 

Soap-box containing Castile soap. 

Infant's hair brush and fine comb. 

Eight ounces of a saturated solution of 
boracic acid for mouth and eyes. 

One-half pound of absorbent cotton. 

A package of wooden toothpicks. 

A bottle of white vaseline. 



The Baby-Basket 

A bath thermometer. 

One yard of plain sterile gauze. 

Plenty of soft old linen. 

Six of the best baby towels. 




FIG. I. BABY-BASKET 



A white eiderdown blanket one and one- 
half yards long. 

One pair of small scissors. 



Clothing to be Provided 3 

A package of nickel-plated safety-pins 
(three sizes). 

CLOTHING TO BE PROVIDED 

Forty-eight cotton diapers, made from 
birdsey e cotton diaper ; two sizes are necessary . 

(a) Three pieces 20 in. 

(b) Three pieces 22 in. 

One yard of white flannel for belly-bands. 
Leave the piece as it is, to be used by the 
trained nurse as required. After the sixth 
week knitted bands with shoulder straps are 
preferable. 

Four second-size silk-and-wool shirts. 

Six pinning blankets made of white flannel 
with cotton bands. 

Three flannel skirts. 

Three white skirts. 

Six night slips to be used day and night 
for five or six weeks. 

Six day slips as plain as possible, bishop 
style. 

Three eiderdown wrappers. 

Three cashmere sacques. 

THE FIRST DUTY TO THE CHILD 
With the severing of the umbilical cord 



4 First Duty to the Child 

the child begins an independent existence. 
It is made to cry, the eyes and mouth receive 
attention, when it is wrapped in a soft, warm 
blanket and placed out of draughts until it 
can be given further attention. During the 
excitement of the occasion and the needs of 
the mother the baby is sometimes neglected, 
often with serious consequences. I once 
saw, with another physician, a fatal case of 
pneumonia in a child four days old, the dis- 
ease being due in all probability to neglect. 
It must not be forgotten that the baby has 
been suddenly transported into an entirely 
different sphere of action from that to which 
he is accustomed, and we must make the 
change as easy for him to bear as possible. 
As soon as the nurse can devote her attention 
to the baby he should be gently and thor- 
oughly oiled with liquid albolene or sweet oil. 
This is to be followed later by a sponge bath 
with lukewarm water and Castile soap. The 
stump of the cord should be dusted with some 
dry antiseptic powder and wrapped in dry, 
plain sterile gauze. The cord, particularly 
at its junction with the abdomen, should be 
thoroughly dusted twice a day. When it 
falls off, the parts should be kept dusted and 



The Well Baby 



dry until cicatrization is complete. The 
following powder has proven most satis- 
factory in my hands : 

Salicylic acid, 15 grains. 

Powdered starch, 1 ounce. 

Powdered oxide of zinc. 1 ounce. 

THE WELL BABY 

In order to appreciate disease or failure in 
proper growth and development, it is neces- 
sary to know what constitutes a well baby. 
The well baby grows steadily, shows an in- 
crease in weight of from five to six ounces a 
week, the muscles are firm, the skin clear, 
and the eyes bright. When hungry he makes 
it known by crying lustily. At the com- 
pletion of the feeding he gives evidence of 
comfort by drowsiness, or by falling asleep. 
There are two or three soft yellow stools 
daily. After the second month the well baby 
appreciates a moderate amount of attention, 
and is attracted to bright objects and pleas- 
ant faces. His sleep is restful, and he wakes 
good-natured unless he is hungry. It is 
not to be understood that the well baby 
cries only when hungry. He often cries 
while being undressed, when the clothing 



6 The Well Baby 

is uncomfortable, when objectionable people 
appear before him, or when suffering from 
pain. 

At the fourth or fifth month he should be 
able to hold his head erect without support ; 
from the sixth to the seventh month — at 
this time the first tooth is usually cut — he 
acquires the power of sitting up without 
assistance; from the ninth to the tenth 
month he begins to creep, and from the 
twelfth to the eighteenth month he learns 
to walk alone. A very few children walk 
alone before the twelfth month; the great 
majority, however, are from fifteen to eigh- 
teen months before this important feat is 
accomplished. There is nothing to be gained 
and much harm may be done by parents 
favoring early walking. When the child 
learns to walk unaided, it is usually safe to 
allow him to continue, unless he is very 
heavy. A child four or five pounds over 
weight should be carefully watched and the 
walking prevented to any extent until he is 
seventeen or eighteen months of age. Early 
walking in these heavy children is very apt 
to produce flat feet, knock-knee, or bowed- 
legs. 



Weight of the Well Baby 7 
THE WEIGHT OF THE WELL BABY 





BOYS 


GIRLS 


Average weight at birth 


7.55 lbs. 


7.16 lbs. 








' three months 


n-75 " 


"•5 " 








' six months 


16. " 


i5-5 " 








' nine months 


18. 


17-75 " 








1 twelve months 


20. 


19.8 " 








1 eighteen months 


22.8 " 


22. " 








' two years 


26.5 " 


25.5 








' three years 


3^5 :; 


3°- 








' four years 


35- 


34. 








1 five years 


41.2 


39.8 " 


" six years 


4.S-I " 


43.8 " 



Every child under one year of age should 
be weighed once a week. The very weak 
and delicate and those who are being put 
through a new course of dietetic treatment 
on account of failure in growth, should be 
weighed two or three times a week. An 
infant is doing fairly well who gains on an 
average four ounces a week, ten months in 
the year. Such a child, however, needs care- 
ful watching. If he gains from six to ten 
ounces a week, we are perfectly satisfied with 
his progress. The use of the weight chart 
I do not advise. Such a chart, while recom- 
mended by many well-known writers, has 
been the cause of serious trouble. The 
mother and nurse wish the baby's weight 



8 Weight of the Well Baby 

chart to make a good showing — to show 
something phenomenal if possible — for the 
admiration of relatives and friends. Some 
perfectly well, vigorous babies increase in 
weight slowly, but a gain of only four or five 
ounces a week — below r the standard of her 
neighbor or the normal weight line on the 
chart — makes a very unsatisfactory chart, 
and the mother in consequence begins to 
worry, fearing that her baby is not being 
properly nourished. Worry and anxiety 
have caused the milk of hundreds of mothers 
to fail, and rendered further nursing impos- 
sible. If the babe is wet-nursed and the 
chart does not show a large gain, the mother 
scolds, the family generally is dissatisfied, 
the wet-nurse becomes angry, and, fearing lest 
she lose her position, her milk soon fails and 
she is unable to nurse the baby. If the baby 
is bottle-fed, there is a strong tendency to 
overfeed him in order to make a pretty chart, 
and as a result the child is made ill. 

The gain in weight is much less in summer 
than during the cooler months. I have seen 
many children in perfect health pass through 
July and August without gaining an ounce; 
but with the arrival of cooler weather they 



How to Lift the Baby 9 

will surely make up for the time lost. There 
is usually a decided loss in weight the first 
four days of life. This loss — from a quarter 
to a half pound — will usually be regained in 
five or six days if the child is properly fed. 
At the end of the first year the child should 
weigh two and one-half times as much as at 
birth. There should be a gain of about seven 
pounds during the second year. 



HEIGHT IN INCHES FROM BIRTH TO 



At Birth. 
Boys, 20.6 
Girls, 20.5 

18 months 
Boys, 30 
Girls, 29.7 



SIXTH YEAR 

6 months 
25-4 
25 

Two years 
3 2 -5 
3 2 -5 



12 months 
29 

28.7 

Three years 
35 
35 



Four years Five years Six years 



Boys, 38 
Girls, 38 



41.7 
41.4 



44.1 
43-6 



HOW TO LIFT THE BABY 

A baby should be lifted by placing one 
hand under the buttocks and the other under 
the head. Until the fifth or sixth month is 



io The Nursery 

reached, a child should never be raised with 
the head unsupported. 

THE NURSERY 

The nursery should be the largest and best 
ventilated room in the house. In a city- 
home it is best to have it on the third or 
fourth floor with a southern exposure. In 
apartments, quiet and the possibility of free 
ventilation and sunlight must be considered 
in selecting the room. For the sake of quiet 
the nursery should not communicate with 
the sleeping-rooms of older children. 

In placing children in sleeping-rooms or 
in a nursery, or in estimating the capacity of 
hospital wards for children, it is to be re- 
membered that at least one thousand cubic 
feet of air-space should be allowed to each 
child. 

The floor of the nursery should not be 
carpeted. A hard-wood floor is best. If 
this is not possible, covering the floor with 
oil-cloth or linoleum is always possible. 
This can be cleaned with a damp cloth every 
day. A broom should never be used in a 
nursery. Paint or hard finish on the walls 



The Nursery n 

is preferable to paper. There should be at 
least two windows and an open fireplace. If 
possible, the bath-room should be connected 
with the nursery, to be used not only for 
bathing the child but as a ' 'changing room." 
The child's napkins should not be changed 
in its living-room if it can be avoided. It is 
needless to say that napkins should never be 
dried in the nursery. 

Steam heat as ordinarily used to-day is the 
least desirable means of heating, on account 
of its uncertainty. In many New York 
apartments of the better class the fires are 
banked at 10 p. m. ; the temperature w T hen 
the child retires is from 70 to 8o° P. or more ; 
by five or six o'clock in the morning a fall to 
from 50 to 6o° F. has taken place. Such a 
change in the temperature with the tendency 
of children to kick off the bed-clothes ex- 
plains many cases of tonsillitis and bron- 
chitis. The temperature of the nursery 
should be kept as even as possible. When 
for any reason this cannot be controlled, it 
is best to have two means of heating, so that 
when one fails the other may be used. The 
open-grate fire or a small wood-stove is best. 
Gas ought never to be employed as a means 



12 The Nursery 

of heating a child's sleeping-room, on account 
of the rapid exhaustion of the oxygen which 
results from its use. 

The furniture of the nursery should be of 
the plainest. Hard-wood chairs and tables 
with enamel or brass cribs or bedsteads 
should be used. There should be no article 
of furniture or furnishings in a nursery that 
cannot be washed. There should be in the 
bath-room or in some room adjoining, a pail 
containing some disinfectant solution, such 
as carbolic acid, one tablespoonful to two 
gallons of water, in which the napkins are 
placed as soon as soiled. 

There should be two shades at each win- 
dow, a light and a dark shade, so that it will 
be possible to darken the room during the 
sleeping time, as well as to exclude the early 
morning light, which is the usual cause of too 
early waking. Babies should be taught to 
sleep until at least six o'clock in the morning. 
This is far better for the child and also for 
the mother if she occupies the same room. 
The unnecessary habit of an early waking at 
four or five o'clock will in most instances 
readily be broken by keeping the room dark. 

The nursery should have suitable means 



Maternal Nursir 13 

for ventilation. For this purpose, aside 
from the fireplace, I have found the window 
board of no little service. It can be made 
of any width. Ordinarily. I have it 
made about four inches wide. It is sawed 
so as to fit tightly under the Lower .-ash. This 
leaves an open space corresponding to the 
width of the board between the upper and 
lower sash, and allows the entrance of a 
rent of air which is directed upward. There 
should be a thermometer in every child's 
living-room or nursery. It should register 
from 70° to 72° F. by 3ay and from 6o° to 
6- z P. by night. The nursery should be 
given an hour's airing twice a day. The 
child should sleep alone in its crib. It sh : v.i 3 
sleep with an adult or an older child. 
The old-fashioned cradle in which genera- 
tions have been rocked may be an interest- 
ing heirloom, but under no circumstances 
should it be removed from its place in the 
garr : 

MATERXAL XURSIXG 

Writers on this subject are very apt tc 
state that the ability of the mother, par- 
ticularly among the well-to-do, to fulfil this 



M Maternal Nursing 

most important function is surely decreasing. 
This may have been a true statment a dec- 
ade ago ; at the present time, however, I am 
sure it is erroneous. In my own medical 
life I have seen a change for the better, par- 
ticularly during the past five years. The 
young mother of today is better able to nurse 
her offspring than was her sister five or ten 
years ago. I attribute this to the fact that 
the youth of the present day are more vigor- 
ous, more nearly normal individuals than 
were those of a decade ago. The inability 
to perform the nursing function so that it will 
be successful has always been attributed to 
the mother per se. This, I think, is an error. 
Not every breast-milk for two or three weeks 
after parturition is ideal, as I have found by 
the examinations of hundreds of them. If a 
child is born with a generally enfeebled vital- 
ity, it keenly feels any slight abnormality in 
the milk, or it may not be able to digest per- 
fectly normal milk; in either event, the milk 
disagrees and the nursing is discontinued. 
Breast-milk during the first two or three 
weeks of the infant's life is produced under 
conditions which are unfavorable — condi- 
tions which do not indicate the possibilities 



Maternal Nursing 15 

of the breast as a secreting organ. Follow- 
ing, as it does, upon the stress of confinement, 
it is not indicative of what may be possible 
later when the customary life and daily habits 
are resumed. Repeatedly I have found a 
very high fat or a high proteid, or both, dur- 
ing the first week or two, entirely corrected 
later without interference. This condition 
at the time was considered sufficiently serious 
to warrant the discontinuance of nursing on 
the part of a weakly infant, while in a vigor- 
ous infant it would be entirely ignored. 

The change which enables more mothers 
successfully to nurse their infants is due to 
two causes- — more vigorous fathers and 
mothers and more vigorous offspring. Fol- 
lowing this line of reasoning, the more normal 
the mother, the better able is she to perform 
this normal function. That this is the case 
is due, I believe, to the fact that growing 
girls and young women are leading more 
hygienic lives than formerly. The making 
of golf, bicycle and horseback riding, boating, 
and automobiling popular and fashionable — 
in short, the taking of girls out-of-doors and 
keeping them there a considerable portion 
of the day — has worked a marvellous change 



16 Maternal Nursing 

for the better, both physically and mentally. 
A neurotic mother makes the poorest pos- 
sible milk-producer. Proportionate to the 
population, there are fewer neurasthenics 
among the young women to-day than there 
were ten years ago, and there will be still 
fewer ten years hence. At the present 
time the timid, retiring young woman of the 
neurasthenic type is not popular in her set. 
It is a fortunate thing for the future of the 
human race, at least for that portion of it 
ich resides in the United States, that the 
young woman has transferred her allegiance 
from the crochet and embroidery needle to 
the golf club. It may be said that our argu- 
ment holds only with the wealthy or the well- 
to-do. Imitation is one of the strongest 
characteristics of the human race, and this 
tendency in America to outdoor hygienic 
living pervades all classes. Saturday half- 
holidays, the excursions and outings afforded 
by reduced rates of transportation, are much 
more popular than they were ten years ago. 
Food is better selected and better prepared, 
owing to increased knowledge on the part of 
the people as to what constitutes proper 
nutrition. These are facts, in spite of the 



Maternal Nursing 17 

sensational novelists and magazine- writers. 
A feature which marks an important ad- 
vance in the right direction is the establish- 
ment of a department in dietetics and food 
economics in the New York Training School 
for Teachers. The Dean, Dr. James E. Rus- 
sell, in establishing this course, is producing 
benefits which reach farther than he realizes. 
The students are taught food values, food 
preparation, and food economics, which con- 
sists in providing for a given amount of 
money the most nutritious food in its most 
attractive form. Hundreds of teachers are 
sent out from this institution every year to 
take their places of usefulness as instructors 
of the young in all portions of the country. 
Each has learned something of food values, 
and better still each has had impressed upon 
him or her the importance of the proper 
nutrition of a growing child. They are 
taught that, without this, the best possible 
type of adult cannot be produced. As a 
result of such instruction they will be of far 
greater service in their fields of labor, for not 
only can they teach what is laid down in the 
books, but, what is equally if not more im- 
portant, they are competent to teach those 



1 8 Maternal Nursing 

under their care how to live ; and those who 
live properly, grow properly, following out 
the maxim of Herbert Spencer that ' 'the 
first requisite for success in life is to be a good 
animal ; and to be a nation of good animals 
is the first condition of national prosperity." 
It may be thought that we have wandered 
far from our subject — maternal nursing, but 
such is not the case; for conditions which 
relate to this important function, even re- 
motely, demand our respectful consideration. 
The food and care of the growing girl have 
the most intimate bearing upon her future 
life, and if she is to be called upon to perform 
the most important function of womanhood, 
she surely has the right to demand that she 
receive during her girlhood proper prepara- 
tion, which heretofore has too often been 
denied her. 

It is not pleasant to criticise physicians; 
but friendly criticism should always be wel- 
comed. The family physician does not, in 
a great majority of instances, fulfil his func- 
tion, or extend his field of usefulness to its 
full capacity, his conception of duty too often 
including only the sick. Unsought advice 
as to the feeding and daily habits of a child's 



Maternal Nursing 19 

life, I find, are usually welcomed and appre- 
ciated by mothers. In practically every 
instance, according to my observation, errors 
in a child's management are due to ignorance. 
Mothers, no matter what their station in life, 
are glad to do what is for the best interests 
of their children when it is made clear to 
them. It is the duty of the physician to 
take the mother into his confidence and ex- 
plain to her the reasons for the line of action 
advised. When she appreciates the reason 
for certain procedures, I find that she is far 
more apt to follow them. I am confident 
from observations upon many cases that if 
I could have the physical direction of ten 
average girls in any station in life, provided 
that they could have the benefit of fresh air 
and good food from infancy to adolescence, 
successful nursing mothers could be made 
out of eight of them. Certain rules of life 
having a direct bearing on nursing lead us 
nearer the ideal and may enable one who 
otherwise could not nurse her child to do so 
successfully. These requirements, it will be 
seen, are laid along common-sense lines 
and cause no hardship or mental distress 
— one of the chief requirements of a nursing 



20 Maternal Nursing 

woman being that she shall be mentally 
normal. 

There are few conditions in which we are 
called to act so variable and so uncertain as 
is the production of breast-milk. Breast- 
milk is one of the most precious substances. 
It is invaluable, unless we can put a value on 
human life. The most successful nursing 
age is between the twentieth and thirty-fifth 
years. I have, however, seen it successfully 
carried on in a girl of fourteen, in a woman 
of fifty -two, and in the much-abused society 
girl, while I have seen it fail absolutely in 
peasant women fresh from the fields of 
Hungary and Bohemia. I have seen those 
in whom at first the nursing was most un- 
satisfactory develop into perfect nurses. 

Some mothers will be able to carry on the 
nursing for only two months; others, three, 
five, seven, or nine months. In my expe- 
rience, whether in out-patient or in private 
practice, it is extremely rare for the breast - 
milk to be sufficient for the child after the 
ninth month, 

The following can be laid down as nursing 
axioms ; 

A diet similar to what the mother was 



Maternal Nursing 21 

accustomed to before the advent of mother- 
hood should be taken. 

There should be one bowel evacuation 
daily. 

There should be from three to four hours 
daily spent in the open air with exercise 
which does not fatigue. 

There should be at least eight hours' sleep 
out of every twenty-four. 

There should be absolute regularity in 
nursing. 

There should be no worry and no excite- 
ment. 

The mother should be temperate in all 
things. 

The diet. — I have many times been con- 
sulted by nursing mothers because the nurs- 
ing was unsuccessful or a partial failure, and 
have found that their diet has been restricted 
to an extreme degree. To put on a greatly 
restricted diet a robust young mother who 
has always eaten bountifully of a generous 
variety of foods is one of the best means of 
curtailing the quantity and lowering the 
quality of her milk-supply. When asked to 
prescribe a diet I tell them to eat practically 
as they were accustomed to before the advent 



22 Maternal Nursing 

of pregnancy and motherhood. That this 
particular vegetable or that particular fruit 
should be forbidden, on general principles is 
a fallacy. Food that the patient can digest 
without inconvenience is a safe food so far 
as the nursing is concerned, as may readily 
be determined in any given case. If a wide 
range of diet is prescribed in some individuals, 
a plain, more or less restricted diet is desirable 
in others. Many a wet-nurse who has been 
carefully selected, who to the best of our 
judgment should prove satisfactory, utterly 
fails in a few days to fulfil the duties of the 
office for which she was chosen. In not a 
few instances the failure is due to a very full 
diet of unusual articles of food, the existence 
of which, in many instances, she never 
dreamed of. Indigestion and constipation 
follow, and both the nurse and the baby are 
made ill and the woman's usefulness ceases. 
A woman who has lived and been well on the 
diet and food found in the home of the labor- 
ing man, whether in the city or country, will 
make a far better wet-nurse on this diet than 
if she indulges in food to which she is entirely 
unaccustomed. The diet of a nursing mother, 
then, should in general be as above stated. 



Maternal Nursing 

rsing is 
ar.i a neither sh:ul;l be remittee :: :arry 
it out along only natural lines. Inasmuch 
as there are two lives to be provided for 
insteai :: :::e. mire f::i. particularly if a 
liruii character, may be take:: thai: she may 

: . I: :s 
:: a i"ise that milk be rive:: freely, A glass 
if milk may be take:: ::: the mil air :: the 
afternoon, and eight ounces of milk with 
eight cutties :: :a:meal c: rcretmeal grael a: 
:ei:ir:e, if i: lies net iisagree. lur :uly 
evidence :ha: a :::: is :::: disagreeing is the 
ctniivltu cfthe iigesticm TTher any article 
::' :"■:■: i iisagree 5 ~ith tite m ether, cr if site 
:s ::n:incei that it iisagrees. vhether :r 
net such :s really the case, the f: : 1 si: veil be 

quantities n:t ever :ne cuart tally, eccs. 
meat rsh rtnhry cereals, green vegetables, 
arc steve i fruit i institute a iiasis f:r selee- 
ti:n. The methii if rreraracitu fir the 
iifcerent meals is net arbitrary. 

7": : vve. — A very imvcirtam 

an: ::ten neglectee matter in relaticn e: 
nursing is the ::::::: it:: :f the :: : els There 
must be one free evacuation daily. For the 



24 Maternal Nursing 

treatment of constipation in nursing women 
I have used different methods in many cases. 
The dietetic treatment does not promise 
much. For here, again, manipulation of the 
diet may interfere with the milk production. 
Three methods are open to use: massage, 
local measures, and drugs. Massage is avail- 
able in comparatively few cases. Local 
measures consist in the use of enemas or 
suppositories. Every nursing woman under 
my care is instructed to use an enema at bed- 
time if no evacuation of the bowels has taken 
place during the previous twenty- four hours. 
Many out-patients, in whom constipation is 
very prevalent, indulge in excessive tea- 
drinking, taking often from one to two gallons 
of tea daily. In such patients, where an 
absolute discontinuance of the tea-drinking 
is often impossible and not absolutely neces- 
sary, I usually allow two cups a day. When 
a laxative is necessary, it should be prescribed 
by a physician. 

Air and exercise. — Outdoor life and exer- 
cise are desirable here as they are under all 
other conditions. In a nursing woman, with 
her added responsibility, they are doubly so. 
In order to get the best results, exercise or 



Maternal Nursing 25 

work should so be adjusted as not to reach 
the point of fatigue. The mother whose 
nights are disturbed should be given the 
benefit of a midday rest of an hour or two. 
She should have at least eight hours' sleep 
out of every twenty-four. Certain annoy- 
ances, anxieties, and worries are inseparable 
from the life of every child-bearing woman. 
It should be our duty, however, to explain 
to the mother and to other members of the 
family that an important element in satis- 
factory nursing is a tranquil mind. During 
the lactation period she should be spared all 
unnecessary care and petty annoyances. 

Regularity in nursing. The breast which 
is emptied at definite intervals invariably 
works better than does one which is not, not 
only as regards the quantity, but the quality 
of the milk as well; so that system in breast- 
feeding is almost as essential to milk-produc- 
tion as to its digestion and assimilation. 

After it is demonstrated that the nursing 
is progressing satisfactorily as proved by the 
satisfied, thriving child, I begin with one 
bottle-feeding daily. The advisability is 
obvious; in case of illness of. the mother, if 
she is called away from home, or if, for any 



26 Maternal Nursing 

reason, the child cannot have the breast, the 
feeding is provided for. Another advantage 
is that it gives the mother needed freedom 
from restraint. She is thus enabled to have 
the benefit of a change of scene. Amuse- 
ments and recreations which the invariable 
nursing period denies her can be indulged in. 
As a result of this greater freedom, she is able 
to supply better milk and to continue nursing 
longer than if tied continually to the baby, 
no matter how fond she may be of it. 

Signs of successful nursing. — The child 
shows a gain of not less than four ounces 
weekly. This is the minimum weekly gain 
which may safely be allowed. When a nurs- 
ing baby remains stationary in weight or 
makes a gain of but two or three ounces a 
week, it means that something is wrong, and 
it will usually, but not invariably, be found 
in the milk supply. When the baby is nursed 
at proper intervals and the supply of milk is 
ample and of good quality, he is satisfied at 
the completion of the nursing. If he is under 
three months of age, he falls asleep after ten 
or twenty minutes at the breast. When the 
nursing period again approaches, he becomes 
restless and unhappy, crying lustily if the 



Maternal Nursing 27 

nursing is delayed. When the breast is 
offered, he takes it greedily. The stools are 
yellow and number from two to three daily. 
The weekly gain in weight under such con- 
ditions is usually from six to eight ounces. 

Signs of unsuccessful nursing. — Theoreti- 
cally, even' normal breast baby should be a 
thriving, well baby. That such is not the 
case is an unfortunate fact. The standard 
established for a well baby is not upheld here. 
When the supply of milk is scanty the child 
remains long at the breast and cries when he 
is removed. He shows signs of hunger before 
the nursing hour arrives. A cause of failure 
in breast-feeding, and probably the most 
frequent cause, is a scanty milk-supply. The 
chief nutritional elements in mother's milk 
are: fat, 3 to 4 per cent.; sugar, 7 per cent.: 
proteid, 1.5 per cent. Failure may be due to a 
marked disproportion of these elements, 
which may cause sufficient indigestion and 
resulting loss in weight to necessitate the 
discontinuance of nursing. Thus there ma}' 
be a high fat — from 5 to 6 per cent. ; or very 
low fat — from 1 to 1.5 per cent. In the high- 
fat cases there will usually be diarrhoea with 
green, watery stools. The child strains a 



28 Maternal Nursing 

great deal and there are green stains on many 
of the napkins. In high-fat eases there is 
also regurgitation or vomiting of sour mate- 
rial. Low fat means deficient nourishment 
and may cause constipation. Sugar is rarely 
a cause of trouble in nursing babies. It sel- 
dom varies, ranging from 5 to 7 per cent, in 
the great majority of breast-milks. Young 
children, further, have a marked toleration 
for it. The proteid of mother's milk is the 
most frequent cause of nursing difficulties. 
Like the fat, it may so be decreased that 
nutritional disorder may be induced in the 
patient, or it may be very much increased; 
the latter being usually the cause of colic or 
constipation in otherwise healthy nursing 
infants. In such infants curds may be found 
in the stools, the passage of which is always 
accompanied by a great deal of gas. The 
milk may contain the normal percentage of 
fat, sugar, and proteid, but be scanty in 
amount. Instead of the four or five ounces 
to which the child is entitled, he may get but 
one or two ounces. Whether or not the 
quantity is sufficient can be determined by 
weighing the baby before and after each 
nursing, for twenty-four hours. One ounce 



Maternal Nursing 29 

of breast-milk practically weighs one ounce 
avoirdupois. The quality or strength is 
determined by an examination of the milk 
itself by the physician. Before nursing, the 
child is put in the scales without undressing 
him and the weight noted. He is allowed to 
nurse fifteen minutes. He is then removed 
from the breast and weighed. A child under 
one week should have gained from 1 to ii 
ounces ; at three weeks of age, r| to 2 ounces ; 
four to eight weeks of age, 2 to 3 ounces; eight 
to sixteen weeks of age, 3 to 4 ounces ; sixteen 
to twenty-four weeks of age, 4 to 6 ounces; 
six to nine months of age, 6 to 8 ounces ; nine 
to twelve months of age, 8 to 9 ounces. 

Of course arbitrary limits cannot be fixed 
as to the quantity. Stationary weight or 
loss in weight with a dissatisfied child usually 
means defects in quantity which are readily 
proved by the weighing. To be fed at the 
breast may also cause the child to suffer from 
an excess of good milk, in which event there 
will be vomiting or regurgitation, usually 
associated with colic. When this overfeed- 
ing continues, dilatation of the stomach 
develops, vomiting becomes habitual, the 
child loses in weight, and the breast-milk is 



30 Maternal Nursing 

said not to agree, and often, unfortunately, 
the baby is weaned. This has been the out- 
come in scores of cases. When there is 
habitual vomiting and colic in a nursing baby, 
two things are to be done — the baby must be 
weighed before and after nursing, and the 
milk must be examined. 

I have repeatedly treated children for 
indigestion who were entirely relieved by 
shortening the nursing period. Weighing 
the baby at intervals of from three to five 
minutes and noting the gain has shown that 
the three or four ounces which may be the 
child's stomach capacity was obtained in 
two, three, or five minutes, the excess which 
the child took over this amount being the 
cause of his trouble. Given a free, full breast 
and a vigorous nurser, and one ounce will be 
taken in one minute. When the nursing 
' 'gait" is established, a child should be kept 
up to the schedule. There are few more 
pernicious teachings than that a baby should 
be allowed to nurse when he wants to and as 
long as he wants to. The idea that a nursing 
infant will take no more than is good for him 
is the fruit of inexperience. Recently a 
mother consulted me in regard to putting 



Maternal Nursing 31 

her one-month-old baby on the bottle, as he 
had many green stools, cried a great part of 
his waking hours, and weighed but a few 
ounces more than at birth. Her milk was 
supposed to be ' 'too, strong' ' for the child. 
An examination of the breast and a talk with 
the mother satisfied me that the breast -milk 
was not at fault. An examination of the 
milk proved it to be good average milk — 3.5 
percent, fat, 6 per cent, sugar, 1.45 per cent, 
proteid. A one-day's test by weighing was 
decided upon. He was allowed to nurse one 
minute and rest one minute. During the 
resting period he was weighed. Weighing 
and resting him in this way, it was found 
that in three minutes he got from 3 to 3 \ 
ounces of milk. The nursing was then re- 
duced to three minutes on one breast and 
five minutes on the other, which was the 
"slower" breast of the two. Every sign of 
indigestion promptly disappeared after this 
change. The stools became normal and the 
infant made a satisfactory gain in weight of 
one ounce daily. 

The quantity may be suitable for the age 
of the child, he may not vomit or show a sign 
of indigestion, and yet he may not thrive. 



32 Maternal Nursing 

In such a case an examination or repeated 
examinations of the milk at intervals of two 
or three days will usually show that it is poor, 
below the normal perhaps in both fat and 
proteid. Such a case occurred in the Xew 
York Infant Asylum. A Swedish woman 
was admitted with an infant two months old 
in fair condition. She had an abundance of 
milk and asked for a foster-child, so great 
was her discomfort from the excessive flow 
of milk. The weekly weighings of the chil- 
dren soon revealed that there was no growth, 
and both children upon examination showed, 
after a few weeks, developing rickets. The 
milk was then examined and was found defi- 
cient — fat 1.2 per cent., sugar 5 per cent., and 
proteid 0.73 per cent. 

Signs of instcfficient nursing. — The baby 
remains long at the breast, perhaps one-half 
to three-quarters of an hour. When re- 
moved, he is restless and uncomfortable. 
After a short time, in an hour or less, he is 
very hungry and demands frequent nursings 
day and night. 

Management of abnormal milk conditions. — 
When it is found that the breast-milk is too 
strong or too weak, or when the normal ratios 



Maternal Nursing 33 

of fat, sugar, and proteid are not maintained, 
it may be possible to increase or diminish the 
milk strength. It may also be possible to 
increase either the fat or the proteid when 
desirable. The heavy milk will usually be 
found in mothers who are robust, who eat 
heartily, and who take but little exercise. 
In such a mother, the prescribing of a plain 
diet, allowing red meat but once a day, dis- 
continuing the malt liquors or wine — which 
it will often be found that she is taking, — and 
directing that she walk a mile or two a day, 
will frequently bring the milk to digestible 
proportions. In some cases, however, this 
will not be successful, and the colic, consti- 
pation, and vomiting continue, even though 
the quantity obtained at each nursing is 
within normal limits. In some mothers it 
will be impossible to change the mode of life, 
except perhaps as to the discontinuance of 
alcohol. When such conditions prevail, the 
mother's milk may be modified by giving 
from one-half to one ounce of boiled water 
or plain barley-water before each nursing. 
This is a procedure to which I frequently 
resort. One teaspoonful of lime-water added 
to one ounce of water before each nursing has 
3 



34 Maternal Nursing 

made the breast-milk agree when otherwise 
it would have been impossible. When the 
milk is deficient both in fat and proteid, a 
diet composed largely of red meat, poultry, 
fish, rye bread, or whole-wheat bread, oat- 
meal, cornmeal, with two or three pints of 
milk daily, will often be followed by an in- 
crease both in fat and proteid. The use of 
alcohol in moderate amounts, in the form of 
malt liquors or wine, will usually increase 
the fat. I have frequently seen it advance 
2 per cent, in from two to three days. Disap- 
pointments in improving the quantity or 
quality of the breast-milk, however, are 
frequent. 

In addition to the one bottle which, for 
reasons above mentioned, is given early in 
the child's life, I find it necessary at the sev- 
enth month to add an extra bottle or two. 
Usually at this time the proteid in human 
milk begins to diminish in quantity, and as 
this is the most important nutritional ele- 
ment, an insufficient quantity at this rapidly 
growing period of life is a matter of no little 
importance. At the twelfth month, with 
very few exceptions, my nursing babies are 
weaned from necessity. At this age exclu- 



Maternal Nursing 35 

sive nursings, if one considers the best in- 
terests of the child, are practically out of 
the question. Out of many thousands of 
mothers I recall but one instance where a 
mother was able successfully to nurse her 
child after the twelfth month. This re- 
markable woman, the mother of six children, 
had nursed every one of them exclusively 
and successfully up to the fifteenth or the 
eighteenth month. 

Mixed feeding. — With a diminution in the 
amount of milk secreted, the breast milk, 
must, of course, be supplemented by modi- 
fied cow's milk. This method of feeding is 
usually successful. If the mother of a six- 
months-old baby can satisfactorily nurse 
him three times in twenty-four hours, he is 
given, in addition, three bottle-feedings in 
the twenty-four hours, in this way supple- 
menting the mother's milk. It is best when 
using mixed feedings to alternate the breast 
and the bottle. The modified milk strength 
should be that which is suitable for the aver- 
age child of his age. (See Infant Feeding, 
P a ge 54-) In beginning the use of cow's 
milk, however, it must be remembered that 
at first a weaker strength must be used than 



36 Maternal Nursing 

the child will require for growth, this weaker 
food being necessary in order gradually to 
accustom him to the change of food. If too 
strong a cow's-milk mixture is given at first, 
it will be very apt to disagree, causing colic 
and vomiting. Later, when the child has 
become accustomed to the new food, a 
stronger mixture may be given. When a 
mother cannot give her infant at least two 
satisfactory breast-feedings daily, it is better 
to wean the child. 

Maternal conditions tinder which nursing 
is forbidden. — When the mother has tuber- 
culosis in any of its various forms or mani- 
festations, whether it involves the glands, 
the joints, or the lungs, breast-feeding is to 
be forbidden. In epilepsy and syphilis nurs- 
ing is likewise forbidden. In nephritis and 
malignant disease of any nature, and in 
chorea, nursing should be discontinued. 
Women who are rapidly losing weight should 
not continue nursing their infants. In case 
of serious illness of any nature, such as 
typhoid fever, pneumonia, or diphtheria, 
and upon the advent of pregnancy, nursing 
should be stopped. 

Conditions which may temporarily pro- 



Maternal Nursing 37 

duce an unfavorable effect tipon the breast-milk, 
but not necessitate the discontinuance of nurs- 
ing. — The advent of the first menstruation 
period particularly, and in some cases of every 
menstruation period, is attended with an 
attack of colic or indigestion on the part of 
the child, rarely sufficient, however, to neces- 
sitate the discontinuance of the nursing even 
for a single day. 

Factors influencing the mental conditions 
of the mother, such as anger, fright, worry, 
shock, distress, sorrow, or the witnessing of 
an accident, may affect the milk secretion 
sufficiently to cause no little discomfort to 
the child, and oftentimes the temporary 
lessening of the flow for a day or two. The 
influence of the mental state upon the char- 
acter of the milk was early bi ought to my 
attention while resident physician at the 
Country Branch of the New York Infant 
Asylum. In this institution there were 
usually about two hundred nursing mothers, 
the majority of them from the lower walks 
of life, at least 95 per cent, of the infants being 
illegitimate. The necessity of placing a 
considerable number of these mothers in 
wards, and their living thus in close contact, 



38 Maternal Nursing 

gave rise to rather frequent disputes, and 
not infrequently to fistic encounters of a 
decidedly vigorous character. After a par- 
ticularly active disturbance, several nursing 
infants in the ward would be taken suddenly 
ill, usually with vomiting, diarrhoea, and 
fever. When two or more infants were thus 
discovered ill, we soon learned to know the 
cause when inquiry or evidence furnished by 
hasty inspection of the mother showed that 
she had been particularly active in the affair. 
A small proportion of the mothers were from 
the better walks of life. Letters of forgive- 
ness or reproach or visits of a like nature from 
fathers, mothers, or sisters, have brought 
many a sick baby to my attention and caused 
me many anxious moments. 

Conditions which call for temporary dis- 
continuance of nursing. — During an acute 
illness with fever, such as indigestion, ton- 
sillitis, and minor illnesses of a like nature, 
nursing should be discontinued for a day or 
two. When the infant is removed from the 
breast, it should be our effort to maintain 
the flow of milk. This is best done by empty- 
ing the breast with a breast-pump (page 46) 
at the usual nursing period until the time 



Maternal Nursing 



39 



arrives when the nursing may he resumed. 
In such conditions the advantage of having 
the baby accustomed to one bottle a day 
will at once be appreciated. 

Care of the nipples. — Six hours after de- 
livery or confinement, the nipples should be 
washed with a saturated solution of boric 
acid and the child put to the breast and nurs- 
ing attempted. After this, the attempts at 
nursing should be repeated 
even' four hours, although 
the milk does not appear 
in the breasts until from 
forty -eight to seventy-two 
hours after the birth of the 
child. Colostrum may be 
present, which is useful as 
a laxative and may satisfy 
the child. A further ad- 
vantage of the nursing at 
this time is that it grad- 
ually accustoms both the 
nipple and the infant to what will be required 
of them later. Immediately after the nurs- 
ing the nipple should be carefully washed 
with a saturated solution of boric acid and 
thoroughly but gently dried. A babv should 




FIG. 2. NIPPLE-SHIELD 



40 Maternal Nursing 

never be allowed to nurse on a cracked or fis- 
sured nipple. For this very painful condition 
anipple-shield (Fig. 2) should always be used. 

Giving of water. — From one-half to one 
ounce of a 1 per cent, solution of milk-sugar 
should be given the infant every two hours 
until the milk appears in the breast. Other- 
wise there will be unnecessary loss in weight 
and perhaps a high degree of fever due to 
inanition. 

If the child is restless and uncomfortable, 
it is safe to conclude that he is thirsty, and 
one ounce of the sugar-water will usually 
satisfy him. "With the commencement of 
nursing, accustom the baby to getting his 
food at regular intervals. 

Frequency of nursings. — The new-born 
infant is entitled to ten nursings in twenty- 
four hours. From 6 a.m. to 10 p.m., inclu- 
sive, there should be nine nursings. There 
may be one nursing at 2 or 3 a.m. As the 
child becomes older less frequent nursings 
are required. The following table will be 
found useful in this connection: 

Third to the twenty-first day 10 nursings. 

Third to the sixth week 9 

Six to the twelfth week 8 



The Wet-Xurse 41 

Third to the fifth month 7 nursings. 

Fifth to the seventh month 6-7 

Seventh to the twelfth month 5-6 " 

THE WET-XURSE 
We are called upon to select a wet-nurse 
under various conditions. In a few families, 
particularly in those who have had disastrous 
feeding experiences, we are asked that no 
attempts at artificial feeding be made, but 
that a wet-nurse be engaged in advance of 
the confinement so as to be ready when the 
time for her service arrives. Usually, how- 
ever, our minds turn to the wet-nurse when 
nutrition by other methods is a failure. It 
is well to remember in this connection that 
it is not wise to postpone our resort to the 
wet-nurse too long — until every chance for 
her being of assistance has passed. It may 
take a few days' observation or but a single 
glance at one of these difficult feeding cases 
for us to decide whether a wet-nurse must 
be secured. Certain it is that in a few cases 
we cannot do without them. I see perhaps 
two or three cases a year, usually in consul- 
tation, in which I insist that further attempts 
at artificial feeding be discontinued because 
of the reduced condition of the patient. 



42 The Wet-Nurse 

In the selection of a wet-nurse the age 
during which nursing is most successfully- 
carried on is to be remembered. Other 
things being equal, a wet-nurse should not 
be under twenty-two or over thirty-five 
years of age. The peasant women of the 
continent of Europe make the best wet- 
nurses. A woman should not be selected 
as a wet-nurse without a thorough examina- 
tion both of herself and of her infant. She 
must be free from skin diseases, tuberculosis, 
and syphilis. Whether she is stout or thin, 
tall or short, amounts to little. Neither can 
we place much reliance on the size of her 
breasts. Although full, firm breasts and 
prominent nipples are desirable, the best 
indication as to her nursing ability is the 
condition of her baby. For this reason it 
is best not to select a woman before her baby 
is four weeks old, for by that time his physi- 
cal condition will indicate with considerable 
accuracy the kind of food he has been getting. 
The age of the wet-nurse's milk need not 
correspond with the age of the patient for 
whom she is engaged. As far as age is con- 
cerned, a breast-milk from four weeks to 
three months old will answer for any infant. 



The Wet-Nurse 43 

The results attending the first few days of 
wet-nursing are often most disappointing. 
The radical change which takes place in the 
nurse's habits of life, the leaving of her own 
child to the care of others, sometimes pro- 
duces nervous conditions which may have a 
decidedly unfavorable influence upon her 
milk. So before arriving at the conclusion 
that she will not answer in a given case, she 
should have time to adjust herself to the 
changed conditions. Many a good wet- 
nurse has been ruined, so far as her usefulness 
as a milk-producer is concerned, by over- 
indulgence at the table. She has been accus- 
tomed to a very plain diet and some w T ork, 
which necessarily means exercise. Upon 
assuming her new office she is temporarily 
the most important member of the household, 
next to the baby, and articles of food are 
supplied to which she is entirely unaccus- 
tomed and of which she eats plentifully. 
The result is an attack of indigestion with 
fever, the baby is made ill, and the usefulness 
of the wet-nurse in the family ceases. These 
women usually do best upon a plain diet of 
meat, poultry, fish, vegetables, cereals, and 
milk. If they are accustomed to taking 



44 The Wet-Nurse 

beer, one bottle daily ma}' be permitted. 
Coffee may be allowed to the extent of one 
cup daily, and of tea not more than two cups 
should be allowed. Women of this class are 
almost invariably neglectful of the bowel 
function, so that this must be attended to. 
One free evacuation should take place daily. 
As a rule, the wet-nurse has been accustomed 
to work and will be more contented and 
happy when her time is occupied. Being 
out-of-doors from three to four hours a day 
is of decided advantage to every nursing 
woman. If she possess sufficient intelligence 
to take the baby for his outings, she should 
be allowed to do so. For the comfort of the 
family, it is wise not to let a wet-nurse know 
her full value. When she feels that she is 
indispensable, trouble is apt to follow from 
one source or another. It is particularly 
necessary, therefore, that babies that are 
wet-nursed should be given one bottle-feeding 
daily as soon as they are able to take care of 
it. The wet-nurse will then realize that 
she can be dispensed with in case of miscon- 
duct, or if she leaves with an hour's notice 
the child can be given the bottle until another 
nurse is secured. In the great majority of 



Care of the Breasts and Nipples 45 

my cases it has not been necessary to con- 
tinue the wet-nursing after the children are 
seven months of age, for by this time they 
can usually be fed on the bottle. Of course, 
unless her nursing proves unsatisfactory', a 
wet-nurse should not be dismissed at the 
commencement of or during the summer. 

CARE OF THE BREASTS AND NIPPLES 

After nursing is well established the baby 
should be nursed at about two-hour intervals 
during the day. From 6 a.m. to 11 p.m. there 
should be nine nursings. If he sleeps be- 
tween 11 p.m. and 6 a.m. do not wake him. 
One feeding at 2.30 a.m. is required by a few T 
children up to the third month; the great 
majority, however, do better without it. Be- 
fore and after each nursing the mother's nip- 
ples should be gently washed with a saturated 
solution of boracic acid, using either clean 
old linen or absorbent cotton. The nipples 
should be thoroughly dried after the washing. 

Nursing is often most painful on account 
of cracks and fissures in the nipples. These 
are very apt to occur if the parts are neg- 
lected, and the resulting pain when the child 
nurses is unbearable, necessitating some- 



46 Care of the Breasts and Nipples 

times the discontinuance of the breast-feed- 
ing. The baby should never be allowed to 
touch a cracked or fissured nipple, and a 
nipple-shield (see Fig. 2) should be used 
until the parts are healed. Some babies 
take very unkindly to the nipple-shield, and 
often a great deal of patience must be exer- 
cised before they can be taught its use. If 
the shield suggested does not answer, others 
may be tried. The breast should never be al- 
lowed to become hard or 
painful. If the child does 
not take enough to keep 
the breasts soft a breast- 
pump should be used to re- 
move the remainder. For 
this purpose, the so-called 
English breast-pump (see 
Fig. 3) is the best. With 
the first rush of milk to the 
breasts it is often very dif- 
fig. 2. nipple-shield ficult to pre vent hard, pain- 
ful nodules from forming in 
the glands. The free use of the breast-pump 
and massage with warm oil, if properly carried 
out, will prevent the formation of an abscess. 
When the breasts are large and pendulous, 




Care of the Breasts and Nipples 47 



a support consisting of a bandage firmly 
applied around the chest will often afford 
much comfort and prevent serious trouble. 
In addition to the use of the nipple-shield, 
the cracked nipple should be washed with a 
saturated boracic - acid 
solution after each nurs- 
ing, and dried, when a 
soothing ointment may- 
be applied on old linen; 
such an ointment, com- 
posed of ichthyol fifteen 
grains, vaseline one-half 
ounce, oxide-of-zinc oint- 
ment one-half ounce, 
has given most satis- 
factory results. The 
ointment should be care- 
fully removed with warm 
sweet-oil and the nipple 
washed in alcohol before 
the next nursing. When 
the fissures are healed, 
the nursing may be resumed, allowing the 
child for a few days to take the nipple every 
second or third nursing, thus gradually 
accustoming the nipples to the rough usage. 




FIG. 3. 



ENGLISH BREAST- 
PUMP 



48 Weaning 

WEANING 

When is the nursing baby to be given other 
food, or how long can the breast be relied 
upon to furnish the child its sole nourish- 
ment? If the mother, unassisted, is able to 
nourish her infant completely until it is seven 
months of age, she is doing remarkably well. 
There are very few nursing mothers who can 
pass that period without assistance. Per- 
haps one or two bottle-feedings a day may 
suffice. In many cases the milk will fail 
about the seventh month, and absolute wean- 
ing be necessary. Granting, however, that 
the child is thriving on the breast alone, or 
doing satisfactorily on the breast with only 
two daily feedings, at what age should the 
weaning take place ? I have known just one 
mother out of several thousand who could 
nurse her child to the child's advantage after 
twelve months had passed. I have seen 
many pronounced cases of malnutrition and 
rickets due directly to prolonged nursing. 
Indigestion and diarrhoea are often the out- 
come of prolonged breast-feeding. 

The weaning in health should begin not 
later than the twelfth month. It is best 



Weaning 49 

accomplished gradually by substituting 
bottle-feeding for nursing, giving only one 
bottle the first day, two the second, three the 
third, and so on until in a week or ten days 
weaning is complete. In case the child is 
ill we may be obliged to wean at once, 
when bottle-feeding is substituted for the 
breast, but the milk formula corresponding 
to his age should not be given. To a child 
six months of age give the three-months' 
formula; a child nine months of age should 
receive the six-months' formula. A gradual 
increase to the formula suggested for a child 
the age of the patient may be made if all 
goes well. After the ninth month it is often 
possible to feed from a cup, which is then to 
be preferred to bottle-feeding as a substi- 
tute for the breast. 

Care of breasts during weaning. — When the 
breast-feeding is carried on the usual length 
of time — from nine to twelve months, — the 
process of weaning ordinarily causes little or 
no discomfort. All that is usually required 
is to press out enough of the milk to relieve 
the patient as often as the breast becomes 
painful, which may not be more than two or 
three times a day. When the weaning is 



50 The Selection of Milk 

necessarily abrupt, no little discomfort may 
result. If there is a free flow of milk, which 
is apt to be the case when the weaning must 
take place in the early nursing period, tightly 
bandaging the breasts is required. When 
localized hardened areas occur in the glands, 
they should be massaged until softened, and 
the bandage reapplied and worn until the 
secretion ceases. When the weaning can 
more gradually be done, the best way is to 
give one less nursing every second or third 
day until only two are given. After this has 
been practised for one week, these also can 
be discontinued. In cases where sudden 
weaning is required, a saline laxative, such 
as citrate of magnesia or Rochelle salts, 
should be given every day for five days — 
sufficient to produce two or three watery 
evacuations daily. In the meantime the 
mother should abstain from fluids of all kinds 
up to the point of positive discomfort. 

THE SELECTION OF MILK 

The selection of the milk on which the baby 
is to live is a matter of no little importance. 
There is a vast difference in the quality and 



The Selection of Milk 51 

cleanliness of the milks on the market. Too 
many mothers look upon all milk as being of 
uniform value because it all has a similar 
appearance. While the general character of 
the milk sold has improved greatly as regards 
cleanliness during the past few years, a great 
deal of that used at the present time is unfit 
for food for a baby. New York City mothers 
should insist that the milk used be bottled 
and sealed at the farm, and also insist that it 
be certified by the New York Milk Com- 
mission. Milk if properly produced is ex- 
pensive; it cannot be sold for six or eight 
cents a quart, and mothers will have to pay 
more than this if they get a suitable article. 
The most expensive milk will, as a rule, be 
found safest for use. 

When certified milk or one of the higher- 
class milks is not obtainable, as is the case 
with those whose home is in the country, and 
for the families from the larger cities who 
spend the summer months in more or less 
remote country districts, the matter of secur- 
ing a safe milk is of vital importance. The 
average farmer is notoriously careless in the 
handling of milk, and in the country dis- 
tricts, where the milk supply should be the 



52 The Selection of Milk 

best, it is often as bad as can well be imagined. 
In the country, where the milk is furnished 
by the farmer direct, a special arrangement 
may be made, by which he agrees: that the 
cow's belly, udder, and teats shall be wiped 
off with a damp cloth before milking; that 
the milker's hands shall be washed before 
milking; that the few jets of the fore-milk 
shall be thrown away ; and that as soon as 
the milk is drawn it shall be strained through 
absorbent cotton into a quart milk bottle, 
suitably corked, and placed in a pail of 
cracked ice. The cracked ice and the ab- 
sorbent cotton, are, of course, furnished by 
the consumer. For the extra trouble the 
farmer receives from twelve to twenty cents 
a quart for the milk. The improved milk- 
pail with the small top opening insures a 
much cleaner milk, as it offers much less 
opportunity for droppings to fall into it dur- 
ing the milking. 

For those who have country homes and 
who can control their milk-supply, the above 
precautions may be carried out to the letter. 
By such careful control of the home product, 
and by the use of milk from those dairies 
only which observe the above precautions, 



The Nursing-Bottle and Nipple 53 

the acute digestive disorders of summer 
among my patients are rendered a very un- 
usual occurrence. These precautions, with 
the knowledge of the mother or nurse as to 
w^hat to do at the first sign of a digestive 
disorder, will reduce the number of the so- 
called summer diarrhoea cases to a very 
insignificant figure. 

A further and very essential requirement 
is that all cows used for furnishing milk to 
infants be tested for tuberculosis every six 
months. 

THE NURSING-BOTTLE AND NIPPLE 

There are two requirements that a nursing- 
bottle must fulfil: It must have a capacity 
sufficient for one full feeding, and it must be 
so constructed as to be readily cleansed. 
The oval bottle (Fig. 4) with rounded edges 
answers best. These may be obtained in 
sizes of from three to nine ounces. As many 
bottles are needed as there are feedings in 
twenty-four hours. The bottles should be 
boiled once a day, scrubbed with a stiff brush, 
with hot borax water, and remain in the 
borax water until needed. Two teaspoon- 



54 



Artificial Feeding 




fuls of borax to a pint of water is the strength 
usually used. Before using, bottles should 
be rinsed in plain boiled water. The straight, 
black nipple (Fig. 4) is also pre- 
ferred, for the reason that it 
can be turned inside out and 
easily cleansed. A nipple which 
cannot be turned should never 
be used. After using, a nip- 
ple should be turned and scrub- 
bed with a stiff brush and borax 
water — a tablespoonful of bo- 
rax to a pint of water. When 
not in use, the nipple should 
be kept in borax water. Be- 
fore placing it on the bottle 
it should be rinsed in boiled 
water. The nipples should be 
boiled once a day. The blind 
nipples — those without holes — 
are the best. Holes of the 
required size may be made 
with a red-hot cambric needle. 



FIG. 4. NURS- 
ING BOTTLE AND 
NIPPLE 



ARTIFICIAL FEEDING 

BOTTLE-FEEDING 



When it is decided that the child will have 



Artificial Feeding 55 

to be nourished by other means than the 
breast, we are obliged to furnish a suitable 
substitute for the mother's milk which the 
child has a right to demand. In our selec- 
tion we must be guided by Nature and fur- 
nish a food that will correspond as closely as 
possible to the mother's milk. This can be 
done only by the use of cows' milk properly 
prepared and diluted. Proprietary foods 
and condensed milk furnish very poor sub- 
stitutes, as will be seen under their respective 
headings elsewhere. Cows' milk differs from 
mother's milk in its most important con- 
stituents. Good cows' milk contains pri- 
marily 3.50 to 4 per cent, of fat, 3.50 to 4 per 
cent, of proteid, and 4 to 5 per cent, of sugar. 
Mother's milk on the other hand contains 
3.5 to 4 per cent, of fat, 1.5 percent, of proteid, 
and 7 per cent, of sugar. It will be seen that 
cows' milk contains more proteid (curd) and 
less sugar than is contained in mother's milk. 
We must endeavor to make the proportion 
of the important constituents of cows' milk- — 
the fat, proteid, and sugar — correspond to 
that of mother's milk. This has given rise 
to the term modified milk. Cows' milk is 
made to correspond to that of the mother by 



5 6 Artificial Feeding 

diluting it with water to reduce the proteid, 
and then by adding cream and milk-sugar to 
bring up the fat and sugar to the required 
strength. 

The term modified milk is not a good one, 
for the term " modified' ' does not cover all 
that is done in rendering cows' milk a suitable 
diet, that is, changing it to correspond to 
mothers' milk. We would have very little 
success in infant feeding if this were all we 
did. The milk must be adapted to a child's 
age and peculiarities, so that the term adapted 
milk expresses far better what we wish to ac- 
complish. In adapting milk to an infant, we 
must remember that cows'-milk proteid (curd) 
is more difficult to digest than the proteid of 
mothers' milk, and that frequently a smaller 
amount of fat must be given than is contained 
in mothers' milk. Particularly must these 
precautions be observed in the very young 
and delicate. The gravest error, and one 
most frequently made in cows'-milk feeding, 
is that of giving the food too strong, at the 
beginning. In consequence, the digestive 
organs are overtaxed, the child vomits, has 
colic, suffers from constipation or diarrhoea, 
and, of course, cannot thrive; cows' milk is 



Artificial Feeding 57 

therefore discarded because it did not agree 
with the baby, while it was not the milk but 
the way it was given that was at fault. In 
the feeding formulas given below, the milk 
is adapted to the various ages of infancy and 
not to the child's condition, as that would 
obviously be impossible. These formulas 
will be found suitable for average infants in 
fair health. In the matter of feeding, every 
child is a law unto himself and he must be 
fed individually. For some babies the form- 
ulas suggested will not answer at all. One 
six-months' child may require the nine- 
months' formula, while another may be able 
to take only the three-months' formula. All 
babies of the same age or weight must not be 
expected to thrive on food of exactly the 
same strength. 

It is the duty of the physician to adapt the 
milk to the patient's digestive capacity by 
giving to each the required proportion of fat, 
proteids, and sugar. The signs of successful 
bottle-feeding are the same as of successful 
breast-feeding: comfort, sleep, and an aver- 
age gain in weight of not less than four ounces 
a week. There should be two or three yellow 
stools daily. 



58 Artificial Feeding 

The signs of unsuccessful feeding are vom- 
iting, discomfort after feeding, habitual colic, 
green, undigested stools, and loss, or a very 
slight gain, in weight. A very few children 
cannot take cows' milk in any form. In this 
class belong those who have been badly man- 
aged. They have taken cows' milk too 
strong or otherwise improperly adapted. 
They may have undergone a series of hys- 
terical changes with various proprietary meal 
foods in the hope that something might be 
found which would agree with them and on 
which they might thrive. 

In some cases cows' milk of any strength 
produces colic and vomiting or more often 
diarrhoea. These difficult feeding cases, 
whether the result of the delicate or peculiar 
condition of the child per se or of improper 
feeding, require the greatest patience on the 
part of the physician and mother. Many of 
these cases must be seen by the physician 
every day for weeks before they can be 
brought to take a suitable diet. Milk in 
some must be temporarily discarded and 
substitutes, such as whey, diluted cream, 
barley -water, broths, or malt soups, have to 
be used. After a short time a very small 



Artificial Feeding 



59 



amount of milk may be added to the substi- 
tute which has been found best to agree. 
Should the milk again cause disturbance, 
condensed milk- — one-half to one teaspoon- 
ful — may be given with barley water, in- 
creasing the amount of condensed milk 
gradually if it is found to agree. A wet- 
nurse is almost indis- 
pensable in some of 
these cases. 

Preparation of food. 
— One or two quart 
bottles of the best 
milk obtainable are 
required daily, depend- 
ing upon the formula 
used. The milk, which 
is delivered at six or 
seven o'clock in the 
morning, is at once „ 

° 7 FIG. 

placed in a refrigerator 

(at 50 P. or lower), where it remains for 
a few hours, until it is convenient to pre- 
pare the food. If the milk and cream 
formulas are used (page 61), one bottle 
furnishes the milk, the other the cream. 
The bottle which is to furnish the milk must 




THE CHAPIN DIPPER 



6o 



Artificial Feeding 



be well shaken before using, so as thoroughly 
to mix the milk and cream. In the event of 
using the top-milk formulas (page 65), one 
bottle daily only is required for several 
months. Skimmed milk should never be 
given to an infant excepting as ordered by a 
physician. Boiled water should always be 
used. The milk-sugar 
should be dissolved in 
hot water before mix- 
ing with the milk or 
cream. The cream at 
the top of the bottle 
is known as " gravity 
cream." It should not 
be poured off nor should 
the milk be siphoned 
from under it. The 
same rule applies in 
using top milk (page 65) . 
The Chapin dipper (see 
Figure 5) furnishes the 
best means of removing the cream or in 
obtaining top milk. The upper portion 
of the milk in the bottle is richer in fat 
than that lower down, therefore if only 
the upper dipper or two is removed it 




FIG. 6. ONE PINT GRAD- 
UATE 



Artificial Feeding 61 

gives a mixture too rich in fat. Such be- 
ing the case, no matter how little cream 
or top milk may be required, all should be 
removed from the bottle as indicated in 
the formula used and placed in a clean pint 
graduate (see Fig. 6), which is to be used 
for all measuring purposes, and stirred a 
trifle to make it of uniform strength. If the 
required amount of cream or top milk cannot 
be obtained from one bottle, another pint or 
quart of milk should be purchased, but cream 
purchased as such should never be used for 
infant feeding. 

Milk and cream feeding. — The following 
formulas for the different ages may be found 
useful for well babies : 

From the first to the third day: 

Milk-sugar J ounce. 

Water 16 ounces. 

One-fourth to one ounce every two or three 
hours. 

From the third to the tenth day: 

Gravity cream J ounce. 

Milk 3 ounces. 

Milk-sugar i ounce. 

Lime-water J ounce. 

Water to make 16 ounces. 



62 Artificial Feeding 

Ten feedings in twenty-four hours; i to ij 
ounces at each feeding. 

From the tenth to the twenty-first day: 

Gravity cream ij ounces. 

Milk 5 ounces. 

Milk-sugar i J ounces. 

Lime-water ij ounces. 

Water to make 24 ounces. 

Ten feedings in twenty-four hours; ij to 2 
ounces at each feeding. 

From the third to the sixth week: 

Gravity cream 2 \ ounces. 

Milk 8 ounces. 

Milk-sugar 2 ounces. 

Lime-water 2 ounces. 

Water to make 32 ounces. 

Nine feedings in twenty-four hours; 2 to 3 
ounces at each feeding. 

From the sixth week to the third month: 

Gravity cream 3 ounces. 

Milk 9 ounces. 

Milk-sugar 2 ounces. 

Lime-water 3 ounces. 

Water to make 32 ounces. 



Artificial Feeding 63 

Eight feedings in twenty-four hours; 2 -J to 4 
ounces at each feeding. 

From the third to the fifth month: 

Gravity cream 4 ounces. 

Milk 15 ounces. 

Milk-sugar 2 J ounces. 

Lime-water 4 ounces. 

Water to make 40 ounces. 

Eight feedings in twenty-four hours; 4 to 5 
ounces at each feeding. 

From the fifth to the seventh month: 

Gravity cream 5 ounces. 

Milk 18 ounces. 

Milk-sugar 2 J ounces. 

Lime-water 5 ounces. 

Water to make 42 ounces. 

Six to seven feedings in twenty-four hours; 
S to 7 ounces at each feeding. 

After the fifth month it is my custom to 
add from one to three teaspoonfuls of a cereal 
jelly to each feeding. This may be added to 
the milk mixture when it is made in the 
morning. Thus, if one teaspoonful is to be 
given at each feeding in a case which is get- 



64 Artificial Feeding 

ting six feedings, six teaspoonfuls of the jelly 
may be added to the entire quantity. 

From the seventh to the ninth month: 

Gravity cream 6 ounces. 

Milk 23 ounces. 

Milk-sugar 2 J ounces. 

Lime-water 6 ounces. 

Water to make 48 ounces. 

Five to six feedings in twenty-four hours ; 6 to 
8 ounces at each feeding. 

From the ninth to the twelfth month: 

Gravity cream 7 ounces. 

Milk 32 ounces. 

Milk-sugar 3 ounces. 

Lime-water 6 ounces. 

Water to make 56 ounces. 

Five to six feedings in twenty-four hours; 

7 to 9 ounces at each feeding. 

The use of top milk is preferred by many 
as it necessitates the purchase of but one 
bottle of milk during the early months of 
life. Other than this it possesses no ad- 
vantages over the milk and gravity cream 
feeding. 



Artificial Feeding 65 

Top-milk feeding. — In using top milk for 
infant feeding the milk is allowed to stand 
in a quart bottle at a temperature of 45 ° to 
50 F. for the same length of time as when 
gravity cream is desired — five hours — when 
certain amounts from the top of the bottle 
are removed with a Chapin dipper (Fig. 5) 
and diluted with different quantities of water 
or gruel to which sugar of milk and lime- 
water are added. The milk selected should 
be the cleanest obtainable from grade cows ; 
usually the most expensive is the best. If 
so-called "certified milk" (page 51) is ob- 
tainable, it should be used, as this warrants 
a cleaner food than that furnished by the 
usual market milks. 

From a quart bottle of milk in which the 
cream has risen, dip off from the top with a 
Chapin dipper sixteen ounces and mix. From 
average milk this should contain: 

7.0 per cent, fat; 
3.2 per cent, sugar; 
3.2 per cent, proteid. 

The following formulas are suggested for 
the various ages noted; 



66 Artificial Feeding 

From the third to the tenth day: 

Top milk 3 ounces. 

Milk-sugar i ounce. 

Lime-water \ ounce. . 

Water to make 16 ounces. 

Ten feedings in twenty-four hours; i to \\ 
ounces at each feeding. 

From the tenth to the twenty-first day: 

Top milk 6 ounces. 

Milk-sugar i J ounces. 

Lime-water ij ounces. 

Water to make 24 ounces. 

Ten feedings in twenty-four hours; ij to 2 
ounces at each feeding. 

From the third to the sixth week: 

Top milk 10 ounces. 

Milk-sugar 2 ounces. 

Lime-water 2§ ounces. 

Water to make 32 ounces. 

Nine feedings in twenty- four hours; 2 to 3 
ounces at each feeding. 

From the sixth week to the third month: 

Top milk 12 ounces. 



Artificial Feeding 67 

Milk-sugar 2 ounces. 

Lime-water 3 ounces. 

Water to make 32 ounces. 

Eight feedings in twenty-four hours; 2\ to 4 
ounces at each feeding. 

Front the third to the fifth month: 

Top milk 18 ounces. 

Milk-sugar 2J ounces. 

Lime-w r ater 4 ounces. 

Water to make 40 ounces. 

Eight feedings in twenty-four hours; 4 to 5 
ounces at each feeding. 

From the fifth to the seventh month: 

After this age two bottles of milk are required, 
16 ounces being taken from the top of each 
bottle and mixed. The same rule applies here 
as to the addition of cereals found on page 63. 

Top milk 21 ounces. 

Milk-sugar 2§ ounces. 

Lime-w^ater 5 ounces. 

Water to make 42 ounces. 

Six to seven feedings in twenty-four hours; 
5 to 7 ounces at each feeding. 



68 Artificial Feeding 

From the seventh to the ninth month: 

Top milk 27 ounces. 

Milk-sugar 2§ ounces . 

Lime-water 6 ounces. 

Water to make 48 ounces. 

Five to six feedings in twenty-four hours ; 

6 to 8 ounces at each feeding. 

From the ninth to the twelfth month: 

Top milk 35 ounces. 

Milk-sugar 3 ounces. 

Lime-water 6 ounces. 

Water to make 56 ounces. 

Five to six feedings in twenty- four hours; 

7 to 9 ounces at each feeding. 

After the twelfth month, plain cows' milk 
may be given with the cereal jelly in addi- 
tion to the other articles of diet suggested for 
a child one year old. (See page 73.) 

The cereal jellies are made by boiling the 
cereal selected for three hours. It will be 
noticed that considerable latitude is allowed 
as to the amount of food which is to be given 
at one feeding. This is because of the differ- 
ence in the capacity of individual children. 



Artificial Feeding 69 

After the third month the midnight feeding 
should be discontinued. Seven feedings will 
be sufficient, the first at 6 a.m. and the last at 
10.30 or 11 p.m. Between 11 p.m. and 6 a.m. 
the child should sleep. Babies are easily 
broken from the night bottle by substituting 
a bottle of boiled water or a milk mixture 
greatly diluted with water. The child soon 
discovers that this is not worth waking for. 
As a result of a full night's rest the digestive 
organs are better able to do their work, the 
appetite is increased, and a larger amount of 
food may be given at each feeding. 

The foregoing formulas will be found use- 
ful for the majority of average well babies. 
Those with pronounced digestive peculiari- 
ties should have the food especially adapted. 

When the milk does not agree the cause 
must be discovered. The food as a whole 
may be too strong, when there will be indi- 
gestion and colic, and possibly diarrhoea and 
vomiting. If the food contains too much 
cream there will be looseness of the bowels, 
and colicky stools, with considerable strain- 
ing; there is apt to be regurgitation also. 
The sugar is rarely a cause of trouble, an 
indication of excess being the eructation of 



70 Artificial Feeding 

gas and a regurgitation of sour, watery 
material. It is comparatively rare, how- 
ever, for the fat and sugar to cause any dis- 
turbance if they are given with any degree 
of intelligence; but the proteid — the curd- 
forming element in cows' milk — often gives 
us no end of trouble. Many infants, as pre- 
viously stated, are able to digest only a very 
weak cows'-milk proteid; consequently, at 
the beginning of cows'-milk feeding, when, 
as is often the case, too much milk is used, — 
too strong a food given, — the result is always 
disastrous. This, with too frequent feeding 
and night feeding, comprise the chief errors 
made in cows'-milk feeding; in fact, they 
are the cause of more bottle-feeding failures 
than all other factors combined. Excess of 
cows'-milk proteid is the cause of habitual 
colic, and is an important element in habitual 
constipation. Chronic indigestion, as shown 
by vomiting and undigested green stools, is 
most frequently due to this cause. We 
frequently see children who cannot take 
cows' milk in any form ; they must be given 
cream diluted either with plain boiled water 
or with a cereal water to which milk-sugar or 
cane-sugar has been added. 



Sterilization of Milk 71 

STERILIZATION AND PASTEURIZATION 
OF MILK 

Sterilized milk is rarely used at the present 
time in routine feeding. Milk is said to be 
sterilized when it has been heated to the 
boiling point, 212 P., and kept at this point 
for thirty minutes. 

Pasteurized milk is milk heated to 155 F. 
and kept at this temperature for thirty 
minutes. In heating the milk we have two 
objects in view: to kill the harmful micro- 
organisms which it may contain, and to keep 
the milk sweet for a longer time than would 
otherwise be possible. The degree of heat 
to which the milk is subjected should depend 
upon the season of the year, the source of 
the supply, the age of the milk, and the diges- 
tive capacity of the child. The more the 
milk is heated the more difficult of digestion 
it becomes, and the more liable it is to pro- 
duce constipation ; so that, other things being 
equal, the less we heat the milk the better 
the nourishment we furnish to the child. In 
country districts where the cows are known 
to be healthy, and the milk clean and fresh, 
heating is unnecessary. In cities and large 



72 



Sterilization of Milk 



towns, where the source of the milk may be 
unknown, and where it is from twenty-four 
to thirty-six hours old when it reaches the 
consumer, heating to a moderate degree is a 
safe procedure at any time of the year. Pas- 
teurizing the milk kills most of the dangerous 
germs without materially affecting the diges- 




fig. 7. 



FREEMAN PASTEURIZER WITH BOTTLE RACK 
REMOVED 



tibility, or changing the taste of the milk. 
Among the intelligent and cleanly I advise 
the pasteurization of milk; among the igno- 
rant poor and the careless," — such as we fre- 
quently see in out-patient work,- — the milk 
should be boiled, particularly during the hot 



Feeding after the First Year 

months. The pasteurization of milk is best 
accomplished by the use of the Freeman 
Pasteurizer (see Fig - . Directions for use 
are furnished with the Pasteurizer. 

If for any reason the Freeman Pasteurizer 
cannot be used, the milk may be heated in a 
double boiler. If this is not at hand an ordi- 
nary agate basin may be used. The vessel 
should be placed over a slow fire, with a milk 
thermometer held in the mixture. When 
the thermometer registers i ;c° F.. remove the 
milk from the fire and pour it into as many 
bottles as there are feedings in the twenty- 
four hours. Absorbent cotton should be 
used for stoppers. The bottles should be 
cooled rapidly by placing them in cold water. 
The Freeman Pasteurizer should always be 
used if possible, for the reason that it saves 
much trouble, the temperature to which the 
milk is heated is uniform, it requires no 
manipulation of the milk after it has been 
prepared and heated, and there are no 
chances of the contamination of the milk 
from the air. 

FEEDIXG AFTER THE FIRST YEAR 
At the completion of the twelfth month 



74 Feeding after the First Year 

the average well-regulated baby should be 
weaned, and other nourishment given. If 
bottle-fed, he should receive more than the 
milk and cereals, with w±rich most children 
are fed. The food suitable for the second 
year of life and the method of its preparation 
and administration are subjects upon which 
the masses are most profoundly ignorant. 
A few children at this period of life are under- 
fed, but the great majority are overfed, and 
carelessly given, at improper intervals, un- 
suitable food, wretchedly cooked. Summer 
diarrhoea finds its greatest number of victims 
among those children over twelve months 
of age who have been carelessly fed. The 
dreaded " second summer" robs many homes 
because of ignorant or careless parents. The 
second summer managed properly is hardly 
more dangerous than any other summer 
during the early years of a child's life. It is 
almost a universal custom when the child is 
weaned or given something other than a milk 
diet, to allow him " tastes' ' from the table. 
Very often these tastes comprise the entire 
dietary of the adult. Milk is oftentimes the 
only suitable article of diet that is given. 
Afterward not only is the other food selected 



Feeding after the First Year 75 

unsuitable, but it is given irregularly, and 
supplemented by crackers kept on hand for 
use between meals. During the hot mojiths 
the gastro-intestinal tract is less able to bear 
such abuse and the child becomes ill. Usually 
when the twelfth month is completed I give 
the mother a diet schedule, with instructions 
to begin gradually with the articles allowed, 
in order to test the child's ability to digest 
them. Every new article of food should be 
carefully prepared and given at first in very 
small quantities. All meals are to be given 
regularly, with nothing between meals. With 
many children this expansion of the diet list 
is attended with considerable difficulty. 
They are thoroughly satisfied with the milk, 
and refuse all other forms of nourishment. 
In such cases time and patience are neces- 
sary at the feeding time. The more solid 
articles of diet should be given first, and the 
milk kept in the background. 

Among the underfed seen at this period of 
life are those who were nursed too long or 
those who were kept for too long a time upon 
an exclusive milk diet. A great majority 
of the cases of malnutrition of the second 
year are seen in the exclusively milk-fed. 



76 Feeding after the First Year 

They are pale, soft, flabby, badly nourished 
children. 

The following is a diet schedule which I 
have employed for several years. Each 
mother is instructed to select, from the foods 
allowed, a suitable meal. 

From the twelfth to the fifteenth month: 
five meals daily. 

7 a.m. Oatmeal, barley, or wheat jelly, 
one to two tablespoonfuls, in eight ounces 
of milk. (The jelly is made by cooking the 
cereal for three hours the day before it is 
wanted and straining through a colander.) 
Stale bread and butter or zwieback and 
butter. 

9 a.m. The juice of an orange. 

ii a.m. Scraped rare beef, one to three 
teaspoonfuls mixed with an equal quantity 
of bread-crumbs and moistened with beef- 
juice. Or a soft-boiled egg mixed with stale 
bread-crumbs; a piece of zwieback, and a 
half-pint of milk. 

(Scraped beef is best obtained from round 
steak, cut thick and broiled over a brisk fire 
sufficiently to sear the outside. The steak 



Feeding after the First Year 77 

is then split with a sharp knife and the pulp 
scraped from the fibre.) 

3 p.m. Beef, chicken, or mutton br6th 
with rice or stale bread broken into the broth. 
Six ounces of milk, if wanted. Stale bread 
and butter or zwieback and butter. Many 
children at the above age will take and digest 
apple sauce and prune pulp ; when these are 
given milk should be omitted. 

6 p.m. Two tablespoonfuls of cereal jelly 
in eight ounces of milk ; a piece of zwieback. 
Stale bread and butter or Huntley and 
Palmer breakfast biscuit. 

10 p.m. A tablespoonful of cereal jelly in 
eight ounces of milk. 

From the fifteenth to the eighteenth month: 
four meals daily. 

7 a.m. Oatmeal, hominy, cornmeal, each 
cooked three hours the day before they are 
used. When the cooking is completed the 
cereal should be of the consistency of a thin 
paste. This is strained through a colander 
which upon cooling will form a mass of jelly- 
like consistency. Of this give two or three 
tablespoonfuls served with milk and sugar or 



78 Feeding after the First Year 

butter and sugar or butter and salt. Eight 
to ten ounces of milk as a drink. Zwieback 
or toast. 

9 a.m. The juice of one orange. 

ii a.m. A soft-boiled egg mixed with 
stale bread-crumbs, or one tablespoonful of 
scraped beef mixed with stale bread-crumbs 
and moistened with beef-juice. A drink of 
milk. Zwieback or bran biscuit, or stale 
bread and butter. 

3 p.m. Mutton, chicken, or beef broth 
with rice or with stale bread broken in the 
broth. Custard, cornstarch, plain rice pud- 
ding, junket, stewed prunes, baked apple, 
or apple sauce. 

6 p.m. Farina, cream of wheat, wheat ena 
(each cooked two hours) . Give from one to 
three tablespoonfuls served with milk and 
sugar or butter and sugar or salt and butter. 
Drink of milk. Zwieback or stale bread and 
butter. 

From tJte eighteenth to the twenty-fourth month: 
jour meals daily. 

7 a.m. Cornmeal, oatmeal, hominy (pre- 
pared as in the above schedule). Serve 



Feeding after the First Year 79 

with butter and sugar or milk and sugar or 
butter and salt. A soft-boiled egg every 
two or three days. Hashed chicken on toast 
occasionally. A drink of milk. Bran bis- 
cuit and butter, or stale bread and butter. 

9 a.m. The juice of one orange. 

11 a.m. Rare beef, minced or scraped, 
the heart of a lamb chop, finely cut. Chicken. 
Spinach, asparagus tips, squash, strained 
stewed tomatoes, stewed carrots, mashed 
cauliflower. Baked apple or apple sauce. 
A drink of milk. Stale bread and butter. 

After the twenty-first month, baked po- 
tato and well-cooked string beans may be 
given. 

2.30 p.m. Chicken, beef, or mutton broth 
with rice or with stale bread broken into the 
broth. Custard, cornstarch, or plain rice 
pudding, junket, stewed primes. A drink 
of milk. Bran biscuit and butter or stale 
bread and butter. 

6 p.m. Farina, cream of wheat, wheatena 
(each cooked two hours) . Give from one to 
three tablespoonfuls served with milk and 
sugar or butter and sugar or salt and butter. 
Drink of milk. Zwieback or stale bread and 
butter. 



So Feeding after the First Year 

From the second to the third year: three meals 

daily. 

Breakfast (7 to 8 o'clock). — Oatmeal, 
hominy, cracked wheat (each cooked three 
hours the day before they are used), served 
with milk and sugar or butter and sugar. 
A soft-boiled egg, a lamb chop, hashed 
chicken. Stale bread and butter. Bran 
biscuit and butter. A drink of milk. 

At ten o'clock the juice of one orange may 
be given. 

Dinner (12 o'clock). — Strained soups, and 
broths, rare beefsteak, rare roast beef, poul- 
try, fish. Baked potato, peas, string beans, 
mashed cauliflower, mashed peas, strained 
stewed tomatoes, stewed carrots, spinach, 
asparagus tips, Bread and butter. A glass 
of milk. For dessert: plain rice pudding, 
plain bread pudding, stewed prunes, baked 
or stewed apple, junket, custard, or corn- 
starch. 

Supper (5.30 to 6 o'clock). — Farina, cream 
of wheat, wheatena (each cooked two hours). 
Give from one to three tablespoonfuls served 
with milk and sugar or butter and sugar or 
butter and salt. Drink of milk. Zwieback 



Feeding after the First Year 81 

or stale bread and butter. Twice a week, 
custard or cornstarch or junket may be given 
or a tablespoonful of plain vanilla ice-cream. 
As a rule, three meals answer best at this 
period. With three meals a child has better 
appetite and much better digestion, and 
consequently thrives far better than one 
whose stomach is kept constantly at work. 
Some children, however, will require a lunch- 
eon at 3 or 3.30 p.m., and will not do well 
without it. This is apt to be the case with 
delicate children, particularly those under 
two and one-half years of age. If food is 
necessary at this hour, a glass of milk and a 
graham biscuit, or a cup of broth and zwie- 
back will answer every purpose. Instead of 
the afternoon meal, the child may relish a 
scraped raw apple or a pear. The fruit at 
this time is particularly to be advised if there 
is constipation. Children recovering from 
serious illness will require more frequent 
feeding. 

From the third to the sixth year. 

Breakfast. — Cracked wheat, cornmeal, 
hominy, oatmeal (each cooked three hours 

6 



82 Feeding after the First Year 

the day before they are used). These may 
be served with milk and sugar or butter and 
sugar or butter and salt. A soft-boiled egg, 
omelet, scrambled egg, chop. Bread and 
butter, bran biscuit and butter. A glass of 
milk. 

Dinner, — Plain soups, rare roast beef, 
beefsteak, poultry, fish. Potatoes stewed with 
milk or baked. Peas, string beans, strained 
stewed tomatoes, stewed carrots, squash, 
boiled onions, mashed cauliflower, spinach, 
asparagus tips; bread and butter. For 
dessert: Rice pudding, plain bread pudding, 
custard, tapioca pudding, stewed prunes, 
stewed apples, baked apples, raw apples, 
pears and cherries. 

Supper. — Farina, cream of wheat, wheat- 
ena (each cooked two hours). Give from 
two to three tablespoonfuls served with milk 
and sugar or butter and sugar or salt and 
butter. Zwieback or stale bread and butter. 
Bread and milk. Milk toast. Scrambled 
egg twice a week. Custard or cornstarch 
each once a week; ice-cream once a week; 
bread and butter. A glass of milk. 

When the child has eggs for breakfast, 
they should not be repeated in any form for 



Diet after the Sixth Year 83 

supper. Red meat should be given but once 
a day. When the child has a chop for break- 
fast, he should have poultry or fish for dinner. 
At this age of great activity and rapid growth, 
the child will often demand food between 
dinner and supper. Carefully selected fruit, 
such as an apple, a pear, or a peach, may be 
given at this time, supplemented by a gra- 
ham cracker or two, or by stale bread and 
butter, if it is found that their use does not 
interfere with the evening meal. 

DIET AFTER THE SIXTH YEAR 

When the normal child has passed the 
sixth year the diet may be considerably ex- 
panded, approximating to that of the adult 
in variety: certain restrictions, however, are 
to be borne in mind. Fried foods should not 
be given; highly seasoned dishes, such as pie, 
rich puddings, gravies, and sauces, are to be 
avoided. Salads with plain dressing may 
now be given. Wine and beer, coffee and 
tea, should never be given to children as a 
beverage. A point to be kept in mind in 
feeding children at this age, as well as those 
who are younger, is the proper cooking of 



84 How the Child Should be Fed 

vegetables. Everything in the line of green 
vegetables should be cooked until it can 
readily be mashed with a fork. 

HOW THE CHILD SHOULD BE FED 

In the foregoing articles on feeding the 
author has endeavored to suggest the na- 
ture of the food required by the growing 
child, and the intervals at which food should 
be given. This, however, does not entirely 
cover the subject. A child should never 
dine with adults until he can have adult diet, 
if the circumstances of the family will permit 
him to dine alone or with other children. It 
is a species of cruelty to expect a hungry 
child of tender age to sit at the table, see and 
smell the fragrant dishes, and be forced to 
content himself without complaint with his 
restricted fare. The author recalls this cus- 
tom as a cause of many tears, disputes, and 
fistic encounters with attendants, which 
formed no small part of the daily routine of 
his earty life. 

In feeding, the spoon or fork must come 
in contact only with the food and the child's 
mouth ; when not in use it should be allowed 



How the Child Should be Fed 85 

to rest on the clean table-cloth. If it falls to 
the floor by accident it should be dipped in 
boiling water before using it. Under no 
circumstances should a feeding utensil be 
allowed to come in contact with the li- 
the nurse or mother; time and again I have 
seen mothers and nurses sip or swallow the 
first teaspoonful of the food which is tc 
given, to determine if it is of the proper tem- 
perature. At other times, when the food is 
not particularly attractive to the child, they 
will place the spoon in their mouths as though 
they intended to take it themselves. Others 
will remove from the spoon with their own 
lips adhering particles of food. 

There are few more reprehensible prac- 
tices than the foregoing, and if parents knew 
the dangers to which their children are thus 
subjected they would not for one instant 
tolerate them. Any one of the many forms 
of pathogenic bacteria may be most readily 
transferred to the mouth of the child in this 
It is unquestionably a means of infec- 
tion with tuberculosis, diphtheria, and syph- 
ilis. The germs of tubercul:sis and diph- 
theria are frequently found in the mouths 
of perfectly healthy adults. They cans 



86 Condensed Milk 

symptoms of disease because of the normal 
power of resistance of such adults. The 
resisting powers of the child, however, to 
these micro-organisms are very slight, and 
when they are carried to the delicate mucous 
membrane of the infant's mouth and throat 
they thrive actively, the child develops 
diphtheria or tuberculosis, and the family 
grieve and wonder how the child could ever 
have contracted the disease. 

CONDENSED MILK 

Condensed milk should never be selected 
as a food for a baby if the mother can afford 
to buy cows' milk and can learn how to pre- 
pare and care for it. The child's natural 
food is the mother's milk ; this is what he has 
a right to demand. If mothers' milk can- 
not be furnished we must give a substi- 
tute which will provide the baby with the 
nourishment contained in mothers' milk. 
Analyses by many chemists of thousands of 
samples of good mothers' milk show that it 
contains approximately 3.5% to 4% of fat, 
1.5% of proteid, and 7% of sugar. Con- 
densed milk, diluted one to twelve, i.e., one 



Condensed Milk 87 

part condensed milk to twelve parts of water, 
— the strength taken by a three-months-old 
child, — will give a food containing .5% of 
fat and .6% of proteid, and 4% of sugar. 
Compare these figures with the amount of 
fat, sugar, and proteid contained in mothers' 
milk and it will readily be seen that the baby 
is not getting nearly as much nourishment 
as Nature would furnish him. If the mix- 
ture, using the condensed milk, is made in 
the proportion of one part condensed milk 
to eight parts of w r ater — the proper strength 
for a six-months-old child — there will still 
be less than 1% of fat, and a lower proteid 
than in mothers' milk. Condensed milk has 
its uses, however. Many mothers cannot 
afford to buy fresh cows' milk. Some have 
no refrigerator or ice-box in which to keep it. 
Condensed milk, on account of the cane sugar 
which has been added to it, will remain fresh 
for two or three days after it has been opened. 
It is a most inexpensive means of feeding the 
baby. Further, its preparation is exceed- 
ingly simple, and many mothers are too 
ignorant to appreciate the importance of 
the careful preparation of cows' milk. That 
magnificent charity, the Straus Milk Labo- 



88 Condensed Milk 

ratory, which furnishes properly prepared 
milk at a minimum price, is available for 
comparatively few of the city's poor. 

Condensed milk is for many an absolute 
necessity; but though children manage to 
live on it, they never thrive satisfactorily. 
They all show evidence of some degree of 
rickets, unless fat in some form, e.g., cod- 
liver oil or cream, is given in addition, to 
supplement the food: and very few children 
can take cod-liver oil during the summer 
months. There is another class of children 
for whom condensed milk has served us well 
at various times. They are the young, deli- 
cate infants, with very weak digestive powers. 
Their mothers cannot nurse them, wet-nurses 
are impossible, and, for some reason, the 
smallest amount of cows' milk, most care- 
fully adapted, cannot be tolerated; a single 
teaspoonful of milk or cream in two ounces 
of plain water, whey, weak milk-sugar water, 
or barley water produces colic and diarrhoea. 
I have successfully fed several of these infants 
on a mixture consisting of one part of con- 
densed milk and twelve parts of water. I 
prefer the unsweetened variety. For some 
unexplained reason these children digest the 



Condensed Milk 89 

condensed milk without any inconvenience 
and do fairly well for a few weeks, when the 
secretion of the digestive juices will be better 
established and a weak adapted cows'-milk 
mixture will be borne. Condensed milk is 
also useful in travelling. During journeys 
by land and sea, condensed milk with boiled 
water will furnish satisfactory food for a 
limited time at a minimum amount of 
trouble. 

The following formulae may be found of 
service to those who for any reason are forced 
to use a temporary substitute for adapted 
cows* milk: 

First month of life : 1 part of condensed milk 
to 16 of water. 

Second month: 1 part of condensed milk to 
14 of water. 

Third month: i part of condensed milk to 12 
of water. 

Fourth to sixth month: 1 part of condensed 
milk to 10 of water. 

After the sixth month: 1 part of condensed 
milk to from 8 to 10 of water. 

These are all maximum strengths; for 
many cases a greater dilution will be required. 



90 The Proprietary Foods 

If a child is fed on condensed milk for a 
longer time than a week, cream or cod-liver 
oil should be given,' — each feeding being 
supplemented by from one-half to two tea- 
spoonfuls of cream, or from ten to twenty 
drops of pure cod-liver oil. 

THE PROPRIETARY POODS 

The foods on the market prepared for 
purposes of infant feeding are almost with- 
out number. From our knowledge of the 
composition of mothers' milk we learn what 
nutritional elements and approximately in 
what relative proportions these elements 
must exist in order to supply the child with 
the food which Nature intended him to have. 
The examination of the milk of thousands 
of nursing women shows that it ranges from 
2.5 to 4 per cent, fat, 6 to 7 per cent, sugar, 
and 1 to 1.5 per cent, proteid. These figures 
may be put down as the normal limits of 
human milk, and they are so, simply because 
the infant will thrive and grow when the 
nutritional elements in approximately the 
above proportions are supplied to him. It 
is within these limits that the food must be 
kept in order that there may be normal 



The Proprietary Foods 91 

growth and development; though of ccv 
wide variations from these may be of tem- 
porary occurrence. While the child may 

t and temporarily do fairly well on a 
percentage of fat lower than 2.5, he will in- 
variably show defective growth if the proteid 
remains persistently under 1 per cent. The 
chief disadvantage in the infant foods which 
are used without the addition of cows 1 milk, 

in the fact that they do not contain the 
nutritional elements as they exist in normal 
re.-.st-milk, and besides, of necessity, they 
are all cooked foods. 

In selecting a substitute for mothers' milk 
(page 54) one point is to be kept in mind, 
viz., the substitute should contain, in a 
readily assimilable form, the nutritional 
elements in approximately the proportions 
and forms in which they exist in mothers' 
milk. All other feeding is defective. It is 
not well to put too much reliance on the 
analysis sometimes published by the pro- 
prietary food manufacturer. This type of 
food is decidedly weak in animal fat, for the 
reason that there is no means of keep- 
ing more than a small percentage :: it in a 
food without its becoming rancid. When 



92 The Proprietary Foods 

considerable percentages are indicated in the 
analysis it is certain that it does not consist 
of butter fat. The quantity of animal milk 
proteid is likewise deficient, and what is 
present has been cooked, thus detracting 
materially from its value in infant nutrition. 
Scurvy is not an infrequent result of the 
exclusive use of these foods. 

The uses of proprietary dried-milk foods. — 
It is to be remembered that this type of food 
is condemned because of its being an unsuit- 
able food when used exclusively and per- 
sistently. In constipation in "runabout" 
and older children who are on a general diet, 
the importance of milk in the nutrition is a 
secondary one, and is often an important 
factor in the production of constipation. In 
these cases cows' milk may be replaced by 
one of the proprietary dried-milk foods which 
has a laxative effect, with a good deal of 
advantage. I sometimes employ them 
further in other disordered states. During 
acute illness and in convalescence from ill- 
ness and in certain forms of malnutrition 
they are usually readily digested and may 
help us over difficult places. 

Proprietary foods to which fresh cows' milk 



The Proprietary Foods 93 

is added. — These are not foods in the usual 
acceptation of the term, and if they are used 
alone independent of milk the patient will 
soon present a sorry spectacle. They are 
sugars largely, being composed of maltose 
and dextrin, which are derived from starch. 
Some contain a considerable quantity of 
unconverted starch. When added to the 
water and milk mixtures they furnish the 
soluble carbohydrates in the form of maltose 
and free starch, and thus fulfil this function 
in the food with as good results as, but usually 
no better than, would milk-sugar and a ce- 
real gruel. Maltose is a laxative sugar. In 
case of constipation in the bottle-fed it may 
replace the milk-sugar in equal quantity, 
and as such may be used with decided 
advantage in some cases. In other cases, 
this change to maltose is without effect. 
The claim that when added to cows' milk 
these proprietary foods increase the liability 
to scurvy is without foundation. If the milk 
is given uncooked, the child will not have 
scurvy, regardless of the nature of the sugar; 
if the milk is heated to 160 or 170°]?., the 
child may have scurvy regardless of the sugar. 
The exploiting of photographs of crowing, 



94 The Proprietary Foods 

fat, red-cheeked babies which are used to 
illustrate the supposed virtues of this or that 
manufacturer's food composed principally 
of maltose is not a very high-minded pro- 
cedure on the part of the manufacturer who 
thus stoops to steal the credit which belongs 
to a cow! According to my observation, 
the statement that the addition of maltose 
to cows' milk facilitates its digestion is un- 
founded. I have tried it in many cases, but 
have never been able in consequence to use 
a stronger cows' -milk mixture, a higher 
proteid. The true test of such a measure 
is its use in the delicate and in difficult feed- 
ing cases, and not in well babies who thrive 
regardless of the sugar employed. The mal- 
tose preparations, then, in the sense that 
they may contain a small amount of proteid 
and a laxative sugar, are useful and to be 
recommended when such a carbohydrate is 
needed. 

The proprietary beef foods. — Numerous pre- 
parations of this nature are on the market 
and there has been abundant opportunity 
to test their value. Without going into a 
lengthy discussion as to how and under what 
conditions these preparations have been used, 



Peptonized Milk 95 

it is sufficient to say that as a means of nutri- 
tion in children they play a very unimportant 
part. Their principal use is in illness, in 
which they act as a stimulant, and to a less 
degree as a food. They all make weak pro- 
teid mixtures when diluted so that the child 
can take them. The possibility of supplying 
any great amount of nutrition to the economy 
by their use is small; occasionally, however, 
they may be used to advantage. When milk 
is withdrawn they may be added to the cereal 
gruel substitute. If there is diarrhoea, great 
care must be exercised, as the proprietary 
beef preparations as well as beef-juice may 
increase it. On account of the creatinin 
which they contain, they should not be given 
in any of the forms of nephritis. Another 
feature which limits their use is that a child 
soon tires of them. They can rarely be given 
more than two or three times in twenty-four 
hours. Valentine's is the preparation I 
usually select. It may be given in solution — 
one-quarter to one-half teaspoonful to six 
ounces of the diluent. 

PEPTONIZED MILK 
Milk is peptonized, or predigested, for the 



96 Peptonized Milk 

purpose of partially or completely digesting 
the proteid, the curd, before it is given to the 
patient. As a means of assistance in making 
a milk food assimilable its field of usefulness 
is limited. So-called complete peptonization 
produces a product with a decidedly bitter 
taste, and but few children will take it. Pep- 
tonized milk, however, has other uses than 
as a means of daily feeding. Peptonized 
milk in which there is a complete conversion 
of the casein has been most useful in two 
types of cases. During acute or chronic 
illness when a child cannot take food by the 
natural method, as in diphtheritic paralysis, 
or when he will not swallow on account of an 
acute inflammatory disease of the throat 
such as peritonsillitis, retropharyngeal ab- 
scess, or retropharyngeal adenitis, or when 
he is in a comatose condition from any cause 
except intestinal infection, the feeding of 
completely peptonized milk by gavage, intro- 
ducing it into the stomach through a tube, 
is of inestimable value. In such conditions, 
as a valuable aid in nutrition, frequent refer- 
ence is made to it throughout this book. In 
conditions when stomach-feeding is impos- 
sible either by gavage or the natural method 



Peptonized Milk 97 

— conditions met with in persistent vomiting 
due to acute cerebral diseases, in recurrent 
vomiting, in acute gastric indigestion — and 
as an accessor}' means of feeding when suffi- 
cient nourishment cannot be taken by the 
stomach, the colon-feeding of completely 
peptonized skimmed milk has a decided field 
of usefulness, and in this way I often employ 
it. Feeding by means of the bowel, how- 
ever, is usually possible in children for a few 
days only, because of the local irritation 
produced by the nutriment and by the pas- 
sage of the tube. Skimmed peptonized milk 
with the addition of the white of egg makes 
the best nutrient enema that I have used. 
It should be given at a temperature be- 
tween 90 ° and 95 F. at from six- to 
eight -hour intervals. The tube should be 
introduced at least nine inches. In cases of 
recurrent vomiting I have repeatedly see:: 
both hunger and thirst relieved ::y feeding 
in this way. The following are the different 
methods for the peptonization of milk. 

Immediate process. — Fifteen minutes before 

feeding add from one-eighth to one-quarter 

of the contents of a Fairchild peptonizing 

tube to the milk mixture which is in the 

7 



98 Peptonized Milk 

nursing-bottle ready for use. Place the 
bottle in water at a temperature of from 
no° to i2o° P., and let it remain until fifteen 
minutes have elapsed. The amount of the 
powder used and the degree of heat of the 
water depend, of course, upon the amount of 
milk in the nursing-bottle. 

Cold process. — Put four ounces of cold 
water into a clean quart bottle and dissolve 
in it, by shaking thoroughly, the powder 
contained in one of the Fairchild peptonizing 
tubes; add a pint of cold fresh milk, shake 
the bottle again, and immediately place it 
upon ice — directly in contact with it. 

Partially peptonized milk. — Put four ounces 
of cold water and the powder contained in 
one of the Fairchild peptonizing tubes into a 
clean saucepan, and stir well; add a pint of 
cold fresh milk and heat with constant stir- 
ring to the boiling-point. The heat should 
be so applied that the milk will come to a 
boil in ten minutes. Let it cool until luke- 
warm, then strain into a clean bottle or 
glass jar, cork tightly, and keep in a cold 
place. The bottle or jar should always be 
well shaken before and after pouring out a 
portion. 



Milk for Travelling 99 

Partially peptonized milk, if properly pre- 
pared, will not become bitter. 

Completely peptonized milk. — Put four 
ounces of cold water and the powder con- 
tained in one of the Fairchild peptonizing 
tubes into a clean quart bottle and shake 
thoroughly; add a pint of cold fresh milk 
and shake again; then place the bottle in a 
pail or kettle of warm water — about 115 F., 
or not too hot to immerse the hand in it with- 
out discomfort. Keep the bottle in the 
water-bath for thirty minutes. Put it im- 
mediately upon ice — directly in contact 
with it. 

MILK FOR TRAVELLING 

In making long journeys with infants by 
land or water, the feeding of the child is an 
important matter, and advice is often sought 
by mothers who wish to make the contem- 
plated trip with the least possible risk. It 
is, of course, desirable that no change be 
made in the milk commonly used, and there 
are means of treating the milk and of keeping 
it which enable us to assure the patient of 
reasonable safety. It is my custom with 



ioo Milk for Travelling 

city children to have the milk prepared at 
the Walker-Gordon Laboratory, where at a 
trifling expense small ice-boxes can be ob- 
tained which contain sufficient space for a 
few days' supply of milk and which can be 
conveniently carried on cars and boats. They 
have also larger boxes with a capacity of 
twelve quarts, which may be used for an 
ocean voyage. The smaller box will need 
refilling with ice once or twice a day, which 
is usually readily secured. The larger box, 
for ocean voyages, is packed in ice and placed 
in a cold-storage room of the vessel and will 
not need repacking during the trip. Labo- 
ratory milk, however, is available for com- 
paratively few. 

Milk prepared at home for a journey should 
be cooled to 45 F. as soon as it is drawn, and 
kept at this temperature until it can be ster- 
ilized at a temperature of 212 F. for twenty 
minutes. It then should be cooled rapidly 
to at least 50 F. and kept at this point until 
used. These directions can be carried out 
by any intelligent family. When this is done 
the milk will be safe for use for the time re- 
quired — from seven to eight days. Even 
the suggestion as to the making of an ice-box 



Diet during Illness 101 

can be followed in any town or village. All 
that is required is the ice-box, one-quart 
fruit jars or one-quart milk bottles, and clean 
milk. Those who for any reason cannot 
avail themselves of the milk thus preserved 
will find in canned condensed milk a fairly 
good substitute. If kept on ice and wrapped 
in a clean towel, a can of condensed milk may 
safely be used for three days after opening. 
Formulas suited for the various months of 
infancy will be found in the section on Con- 
densed Milk (page 89). 

DIET DURING ILLNESS 

The digestive capacity of every child is 
diminished during illness, depending largely 
upon the age of the child and the severity 
of the disease. The younger the child, the 
greater the incapacity. This is fairly con- 
stant with all the ailments of childhood, 
including, of course, those which directly 
affect the gastro-enteric tract. In a mod- 
erately severe bronchitis, with a degree or 
two of fever, the digestive capacity is slightly 
diminished and a 25 per cent, reduction in 
the strength of the food will answer. During 



102 Diet during Illness 

the critical stage of a lobar pneumonia the 
digestive powers are held in abeyance and 
predigested foods and alcohol must sustain 
the patient. During an attack of measles, 
scarlet fever, broncho-pneumonia, or diph- 
theria in bottle-fed infants, at the height of 
the disease, it is my custom to reduce the 
strength of the food one-half by the addition 
of water, to make up for the quantity re- 
moved. For ailments of lesser severity, 
such as bronchitis, with a temperature of 
ioo° to ioi° P., or chicken-pox, or mild 
measles, I reduce the strength of the food 
from one-fourth to one-third. In any mild 
ailment or injury which confines a child to 
its bed, the food strength should be cut down, 
for inactivity as well as disease lessens the 
digestive capacity. 

Among nurslings and the bottle-fed these 
precautions are particularly necessary. A 
child with fever is apt to be thirsty and to 
take more food than in health. This is fre- 
quently the case in summer diarrhoea. In 
order to avoid this taking of too much food, 
I not only order the milk to be diluted for 
the bottle-fed, but I instruct the mothers of 
nurslings to give a drink of water immediately 



Diet during Illness 103 

before each nursing and between nursings, 
and then to allow the child to nurse only one- 
half or two-thirds the usual time. For the 
bottle-fed, one-half to two-thirds of the 
contents of each bottle is removed and the 
quantity replaced by boiled water, so that 
the amount of fluid given remains the 
same. 

If the child is a "runabout," over two 
years of age, he is given broths and thin gruel 
— one-half milk and one-half gruel. By 
carefully watching the stools, thus fitting 
the food to the child's capacity, we will avoid 
grave intestinal complications which, during 
the summer, often prove to be more serious 
than the original ailment. In the acute 
gastro-enteric troubles, and in typhoid fever, 
all milk must be discontinued. 

The art of feeding in illness.' — Not only is 
food oftentimes taken in insufficient quantity 
in illness, but in many cases it is absolutely 
refused. In other cases, during coma and 
asthenic states, swallowing is impossible. 
In delirium and in conditions of collapse 
nourishment must be given, and when this 
is impossible by the natural method, we 
have, as temporary substitutes, gavage, oil 



104 Diet during Illness 

inunctions, and rectal feeding- — all referred 
to elsewhere. 

Forcing the child to take nourishment by 
the mouth is rarely necessary. Coaxing and 
bribing ordinarily succeed far better. For a 
child from three to five years of age a bright 
new penny possesses much persuasive power. 
The child will usually take its food better 
from those to whom it is accustomed, like 
the mother or nursery maid. The trained 
nurse should understand that while un- 
acquainted with the patient, the simpler 
requirements of the child are to be looked 
after by others to whom the patient is accus- 
tomed. The nourishment should be as pal- 
atable as possible and served in bowls, cups, 
or plates that are attractive to the patient 
because of color, pictures, or peculiarities of 
shape. Junket, flavored with vanilla, served 
cold is a favorite food for sick children of the 
1 ' runabout' ' age. Frozen custard, and 
home-made ice-cream, made with one-third 
cream and two-thirds milk, will usually be 
well taken. Toast, dry bread, and crackers 
made in peculiar shapes are attractive to the 
child. In not a few cases I have succeeded 
in feeding satisfactorily children two or three 



Vomiting 105 

years old, when several other schemes had 
failed, by allowing the temporary return to 
the bottle, from which they had been weaned 
for a year or so. 

In these difficult feeding cases the child's 
peculiarities and wishes must be studied. 
Children in illness require water. Often- 
times they will take it in insufficient quan- 
tities. Those who refuse plain water will 
often take ginger ale, sarsaparilla, or vichy. 
In the event of these drinks being well taken, 
they may be given freely. In the acute in- 
fectious diseases, which include pneumonia, 
free water-drinking is a therapeutic measure 
of no mean value. 

VOMITING 

A sudden attack of vomiting may usher 
in any serious illness, with fever. Thus, it 
may be the initial symptom of pneumonia, 
scarlet fever, or meningitis. B\ T far the most 
usual cause, however, will be found inti- 
mately connected with the stomach, usually 
an acute attack of indigestion. Bottle-fed 
children furnish the greatest number of pa- 
tients, as these children are almost always 



106 Habitual Vomiting 

overfed, and more or less badly fed. With 
the onset of a sharp attack of vomiting, 
particularly if it occurs during hot weather, 
the milk diet should immediately be discon- 
tinued. Small quantities of boiled water, 
one-half to two ounces of barley water, or 
rice water, or plain broths may be given every 
hour or twx>. In the obstinate cases, quite 
a period of rest should be given the stomach. 
From twenty-four to thirty-six hours will 
often be necessary before the child will be 
able to retain even a teaspoonful of water. 
No milk should be given until the vomiting 
has ceased for at least two days. When the 
milk is resumed it should be diluted five or 
six times with water and at first only a small 
quantity of the mixture given. In many 
of these cases a stomach washing will speedily 
correct the trouble. If the stomach bears 
the food well its strength may gradually be 
increased by an additional half-ounce or 
ounce of milk to each feeding daily, untiHhe 
former diet is resumed. 

HABITUAL VOMITING 
Many children regurgitate or vomit a por- 



Malnutrition and Marasmus 107 

tion of every feeding. This means one thing 
always — the child has been or is overfed. 
He is given the food too strong, or the amount 
is greater than his capacity , or he is fed at too 
frequent intervals. In either case the stom- 
ach relieves itself. Many of these children 
who regurgitate after each feeding thrive 
finely in spite of the loss. Enough is retained 
for their nourishment, and they gradually 
become accustomed to the strong food and 
no serious harm results. Such a stomach, 
however, is liable to behave very badly dur- 
ing hot weather. During any illness, in fact, 
which taxes the patient's strength, the dis- 
ordered stomach stands ready to furnish an 
unpleasant complication. 

The treatment of habitual vomiting in the 
bottle-fed is by a suitable adaptation of 
the food and stomach washing. Among the 
breast-fed the breast-milk will have to be 
examined and, if found unsuitable, corrected 
if possible. If too frequent nursings or night 
nursings have been allowed they should be 
discontinued. 

MALNUTRITION AND MARASMUS 
By malnutrition we understand that con- 



108 Malnutrition and Marasmus 

dition in which a child for some reason fails 
to gain in weight or loses steadily for a con- 
siderable period of time. Cases present all 
degrees of severity, from those in which there 
is merely a temporary loss of weight, to those 
of an extreme degree of malnutrition, which 
latter condition we term marasmus. A ma- 
rasmatic infant presents one of the most 
pitiful pictures we are called to look upon: 
the dry skin drawn tightly over the fleshless 
bones, the sunken eye, the distended abdo- 
men, the anxious, tired expression, and the 
whining cry furnish a picture of starvation 
so pathetic that only those hardened by long 
familiarity with such cases can look upon 
them unmoved. 

When the history of such infants has been 
looked into it will be learned that errors in 
feeding contributed largely to bringing them 
to their woeful condition. Many of these 
children came into the world strong and vig- 
orous, the mothers were unable to nurse them, 
and the food selected did not agree with them. 
Cows' milk, perhaps, was given, unsuitably 
adapted, — it usually is given too strong to 
young infants, — at any rate it disagreed, and 
the proprietary meal foods were brought into 



Malnutrition and Marasmus 109 

use, one after another, as they were suggested 
by well-meaning friends, each to do its share 
of damage and in turn to be discarded. The 
stomach bore the ill-usage for a time, but 
soon became so disturbed that the digestion 
of rational food was out of the question. 
Many of these children finally reach the point 
where predigested foods fail to be assimi- 
lated ; such cases, of course, are hopeless. 

It is a source of amusement oftentimes to 
note the assurance with which laymen will 
advise a mother that such and such a food 
is the only one for the baby, when they pos- 
sess neither the intelligence nor the training 
necessary to judge of the child's digestive 
peculiarities or capacity; in fact, they know 
no more of the child's requirements or the 
chemical composition of the food suggested, 
or even what should be the composition of 
the baby's food, than does the unfortunate 
babe itself. 

If there is inherited weakness, or a low 
vitality from any cause, the downward course 
may be very rapid. There are two or three 
weeks of suffering, and then the end. If seen 
before the vital powers are at too low an ebb, 
these children, by very careful and intelligent 



no Malnutrition and Marasmus 

management, can be saved. They should 
be handled only when necessary for dressing 
and bathing. The nourishment given must 
at first be very weak, and its effects carefully 
watched from day to day, the strength and 
amount of the food being increased or de- 
creased, as may be found necessary. A brine 
bath should be given daily, — a tablespoonful 
of salt to a gallon of water. The tempera- 
ture of the water should be ioo° to 105 F. 
The child should remain in the water ten 
minutes, being rubbed well with the hand 
while in the water. When removed, it should 
be placed in a large bath towel and dried 
quickly. When dry, rub one tablespoonful 
of unsalted lard or goose-grease into the skin. 
Flannel should be worn next to the skin except 
during very warm summer weather. 

Marasmatic children when sleeping should 
not be allowed to remain long in one position ; 
they should frequently be turned from the 
back to the side, and from one side to the 
other. A hot -water bottle to the feet will 
often be necessary when sleeping. To a child 
suffering from malnutrition, fresh air is as 
indispensable as food. During the warm 
weather if he can be protected from the sun 



Summer Diarrhoea in 

the child should be kept out of doors from 
morning until night. During the entire year 
he should sleep with the window open. Dur- 
ing the winter months he should be taken 
out of doors for at least one-half hour every 
pleasant day. When, on account of the 
inclement weather or excessive cold, he can- 
not go out, he should be dressed as for the 
daily outing, taken into a room all the win- 
dows of which have been open for at least 
one-half hour ; here, placed in a baby-carriage 
and warmly covered, with a hot -water bottle 
at his feet, he is allowed to enjoy the fresh 
air for several hours each day. This bright- 
ens the eye, brings color to the cheek, and an 
invigorated baby returns to the nursery. 

SUMMER DIARRHCEA 

Summer diarrhoea is the cause of more 
deaths among young children in our large 
cities than any other one factor. So preva- 
lent and so dangerous an illness should be 
better understood by the laity than is the 
case at the present time. Every illness of 
this nature must be considered as a case of 
poisoning. The vomiting and diarrhoea are 



ii2 Summer Diarrhoea 

conservative efforts on the par: of Xature 
re: rid of the oheitdiitg material. The 

1 1 m ay re d u e t ' d z a e t e n a - 1 a a e r_ m an, u it e _ e a n 
feeding apparatus, or to any means whereby 
:: oisoitous germs hnd entrance into the gastro- 
intestinal tract. 

There may also be an indirect infection or 
self-poisoning — an auto-intoxication. Heat 
plays an important part in these cases. The 
child is greatly depressed: the digestive pro- 
cesses are not properly carried on — the milk 
taken from the breast or bottle is not acted 
upon by dig-stive juices of the usual strength 
ana volume; cecontnosition tanes place i 
poisons are generated and absorbed, produc- 
ing fever and prostration, the intestine en- 
deavors to empty itself of the offending 
material and diarrhoea results. 

Cholera infantum, inflammation of the 
bowels, dysentery — all very baa terms but 
in common use — are due primarily to the 
causes above mentioned. Such being the 
nature of summer diarrhcea. the duties of 
the mother in such cases should be clearly 
understood. The intestine must be relieved 
of as much as possible of the material which 



Summer Diarrh 113 

is causing the trouble. For this pur 
give two teaspoonfuls of castor-oil, and nour- 
ishment which will not furnish a fertile soil 
for the growth of bacteria. For this reason 
must be stopped with the first symptom 
of the trouble. The mother will never make 
a mistake in these cases ; in fact, many a life 
will be saved by an immediate dose of castor- 
oil and by promptly -topping the milk diet 
before the physician arrives. Milk, in addi- 
tion to furnishing a medium for the growth 
of bacteria, forms into tough curds which 
must pass the entire length of the intestinal 
tract, exciting a very active peristalsis, caus- 
ing pain and an increase in the number of 
ages. The diet substituted for milk 
should consist of some cereal water, plain or 
dextrinized ; either barley, wheat, or rice may 
thus be used; broths, whey, or substances 
of like nature may be given alternately or 
combined with the cereal waters. Salt 
should be added to the barley-water if it is 
given plain. I prefer to give one or two 
ounces of chicken or mutton broth with the 
barley-water. A teaspoonful of sherry wine 
or one teaspoonful of liquid peptonoids may 
be added to the barlev -water. Broths must 






ii4 Summer Diarrhoea 

be given in small amounts, as not infre- 
quently they have a decidedly laxative 
effect. 

It is not advisable to give one food con- 
tinuously, as the child will tire of it. The 
addition to the barley-water of one of the 
substances suggested will so change its taste 
that, if necessary, the diet may be continued 
for several days. The quantity should cor- 
respond to the amount of food taken in health , 
but the intervals between feedings should 
be shorter — every two hours if practicable. 
For instructions for cooking the cereal water, 
see Formula, pages oo. 

A patient is not to be considered out of 
danger nor should the milk diet be resumed 
until the stools are normal and not over two 
or three daily. In many cases milk must 
be excluded for two or three weeks. When 
it is resumed, care must be exercised in not 
giving too strong a mixture ; many a relapse 
is due to this error. The first day not over 
one-quarter ounce of milk should be given 
in each feeding of the barley-water. If this 
causes no disturbance one-half ounce may be 
given the next day, increasing from one- 
quarter to one-half ounce daily, if there is no 



Summer Diarrhoea 115 

return of the diarrhoea, until the customary 
strength is reached. Many children will not 
be able to digest nearly as strong a mixture 
as they were taking before their illness, and 
the diluted milk mixture will have to be sup- 
plemented by the use of dextrinized cereal 
gruels, cereal jellies, scraped beef, the white 
of an egg, and other easily digested sub- 
stances. Every year I have patients who, 
after such an attack, cannot take a particle 
of milk without harm until the autumn is 
well advanced. 

Bowel irrigation. — Washing out the bowels 
once or twice a day is also very helpful in the 
treatment of these cases if the stools contain 
any blood or much mucus. This is done as 
follows: A No. 14 soft-rubber English cathe- 
ter, one that will not bend upon itself, if 
properly used, is attached to a fountain 
syringe. The bag should be held three feet 
above the patient, who should lie on the left 
side with the legs well drawn up. The tip of 
the well-oiled catheter is passed into the 
rectum a distance of two inches, when the 
water is allowed to pass in slowly. The 
water will distend the parts and facilitate 
the further introduction of the tube. Press 



n6 Summer Diarrhoea 

the folds of the buttocks together until the 
colon is filled. This, in a child eighteen 
months of age, will require from twenty-four 
to thirty ounces of water. When not less 
than one pint has passed in allow the water 
to pass out alongside the tube. 

Prevention. — A word regarding the pre- 
vention of summer diarrhoea. It is not 
enough that the child be given properly 
prepared pasteurized or sterilized milk or 
breast-milk, — he must be made comfortable 
during the hot weather. The clothing should 
be of the lightest. On very hot days, if in 
the country, he should be kept in the open 
air, in the shade; if in the city, the coolest 
room in a house or an apartment is far better 
than the dusty streets. Whether in the city 
or country, on very hot days two or three 
fifteen-minute spongings with water at 6o° F. 
will add greatly to the child's comfort. 

Reduction of food. — Further, we know that 
the digestive capacity is lessened during the 
heated term, and the milk should be reduced 
in strength from one-quarter to one-third, 
adding boiled water to take the place of the 
milk removed. 

Cleanliness.' — As infection may be carried 



Baths 117 

to the feeding utensils by the hands of the 
nurse or mother, she should always wash 
them most carefully with soap and water 
before handling bottles or nipples, or pre- 
paring the infant's food. Inasmuch as other 
children may become infected, or reinfection 
take place in the one already ill, a child with 
summer diarrhoea should be isolated. 

BATHS 

The newly born child should be given daily 
a basin-bath with lukewarm, boiled water and 
castile soap until the cord falls and the navel 
heals. When this has taken place the tub- 
bath may be given. The temperature of the 
bath for the very young infant should not be 
below 95 F. nor above ioo° P. Very young 
children should not be kept in the water more 
than three minutes. After the third or 
fourth month a temperature of 90 or 
95 F. is best, the child being kept in the 
water about five minutes. At this age I 
prefer to have the tub-bath given at night, 
just before the child is put to bed. A basin- 
bath may be given in the morning. When 
the child is a year old and fairly vigorous, 



1 18 Baths 

the temperature of the water at the begin- 
ning of the bath should be 90 ° F. This 
should gradually be reduced to 80 ° F. by 
the addition of cold water, the child being 
vigorously rubbed with the hand while in 
the water. The temperature of the room 
should be from 7 6° to 80 ° F. during the bath, 
and windows and doors should be closed. 
When removed from the tub the baby should 
be dried quickly and thoroughly, and the 
folds of the skin should be well powdered. 
A sponge should never be used in any portion 
of the bathing process. It should never be 
included in the nursery outfit. It is never 
clean after it has once been used. Some 
children have a dread of the bath, and cry 
frantically when placed in the water. This 
is due to fear, and may usually be overcome 
by placing a sheet over the tub and lowering 
the child on it into the water. 

The cold douche. — For "runabouts" from 
two to three years old it may not be wise to 
use water below 70 F., but many patients 
over three years have the water applied in 
the form of a cold douche after the cleansing 
bath, during the entire twelve months at the 
temperature at which it runs from the faucet. 



Baths 119 

In winter, in New York houses, this ranges 
from 50 to 6o° F. 

In giving the cold douche the child should 
stand in warm water covering the ankles. 
The douche may be used in the form of a 
spray or shower or the water may be applied 
by means of a sponge moistened with it at 
the desired temperature. The head, if the 
shower or spray is used, should be suitably 
protected by an oil-skin or rubber bathing 
cap. 

After the cold douche there should be a 
vigorous friction of the skin with a rough 
towel. If there is not a quick reaction, if the 
skin does not become warm and glowing, 
warmer water should be used. So also with 
blueness of the extremities and " goose flesh " ; 
use water less cold, but do not discontinue 
the douche. 

In the great majority of homes the bathing 
of the children can be carried on with greater 
convenience immediately before their bed- 
time. The child should receive the warm 
bath and the cold douche, and then, in 
night-clothes, a warm wrapper, and suitable 
foot covering, he should eat his supper. How- 
ever, if this time is not convenient, he may 



120 Baths 

be given the evening meal at 5.30 or 6.30, 
followed in one hour by the bath and bed. 

Tub-baths for fever. — Place the child in 
water at a temperature of 95° F. and reduce 
to 75° or 8o° F. by the addition of ice or 
cold water. The duration of the bath should 
not be more than ten minutes, constant fric- 
tion being maintained during the entire 
process. 

Basin bathing for fever. — Add eight ounces 
of alcohol to a quart of water at a tempera- 
ture of 7c F. The child is stripped and 
covered with a flannel blanket, and the entire 
body sponged with this solution for ten or 
fifteen minutes. 

Either the tub-bath or the basin-bath may 
be used by the mother in case of sudden high 
fever — 104° to 105 F. — before the physician 
arrives. She should be so instructed. 

Bathing for comfort in hot weather. — The 
basin-bath and tub-bath may also be used 
as a means of relief during very hot weather. 
One or two basin-baths a day, with a tub- 
bath at bedtime during this trying season, 
will give the child much relief, and help him 
to pass safely through it. The very young 
feel the extreme heat most acutely, and 



Baths 121 

endure it with difficulty. I know of nothing 
else that will give a restless, uncomfortable, 
heat-tormented child such a refreshing sleep 
11 a cool basin-bath. 

Mustard bath. — A mustard bath is pre- 
pared by adding a heaping tablespoonful of 
mustard to six gallons of warm water. One 
c: the uses •:: the rasia: 1 ":: ;vh is in the :rea:- 
•ment of convulsions; it will be found useful 
also for nervous children who sleep badly. 
Two or three minutes in the mustard water, 
:;h ea :y a :va:h ra'vvirr invrieaiately 
cefire r:irvt :: :e:l. is : nervines all :ha: 
will :e: - : : iravze refreshing sle 

I :ne : atla — an even ta: le- 

st : :r:ul :: sal: :: :ne tallzr :: vvaier — is :: 
vrea: service vrhh very telltale. : airly niar- 
aailaren. Its aiviin is that ci a tin:: 
I: :he :hilt is ihiriarhly siatea ana vashea 
with plain water, ana then immersed the 
brine bath, no furth ring is necessary. 

The child should be kept in the bath for five 
or ten minutes, constant friction being con- 
tinue:, aiming the entire tirae. 

5;.:.: ::.:': — Ta - s: is : ath 1st: same service 
in cases of prickly heat from which many 



122 Earache 

spoonful of bicarbonate of soda should be 
added to each half-gallon of water used. The 
temperature of the water should be that to 
which the child is accustomed. From two 
to four minutes in the water suffices. There 
should be little or no friction of the skin. The 
child should be dried with soft towels. 

Bran bath. — The bran bath also is of service 
in prickly heat. One cup of bran is mixed 
with the water in the bath-tub and the same 
method employed as for the soda bath. 

Starch bath. — The starch bath also is useful 
in prickly heat. One-half cupful of pow- 
dered laundry starch is mixed with the water 
in the bath-tub, and the same method em- 
ployed as for the soda bath. 

Hot bath. — Place the child for from three 
to five minutes in water which has been raised 
to a temperature of 105 to no° F. Con- 
stant friction of the extremities is maintained 
while in the water. 

EARACHE 

Infants and young children are very sus- 
ceptible to attacks of earache. They usually 
occur in children who are suffering from some 



Earache 1 23 

inflammatory condition of the throat or nose. 
Such, however, is not necessarily the case. 
I have seen earache in children who appar- 
ently were in perfect health. In the very 
young the only symptoms of the trouble may 
be restlessness, fever, which is usually pres- 
ent, and pain, which is manifested by crying. 
I have repeatedly seen an attack so severe 
as to cause an infant to shriek with pain, 
without any sign to locate the trouble. An 
older child, in addition to the above, will 
usually raise the hand to the side affected 
or point to the painful ear. The child usually 
is much disturbed if the ear is touched or 
manipulated in any way. While- severe pain 
is the rule, it may be absent ; there may be 
loss of appetite, high fever, and restlessness 
for three or four days with no other sign of 
illness, and no evidence whatever of pain, 
when suddenly one discovers a yellowish 
discharge from the ear, with temporary or 
permanent relief from the symptoms. 

In case of an attack of earache, dry heat 
is of much service. Rest the ear on a hot- 
water bag, or apply a salt bag, made by sew- 
ing together two pieces of muslin about three 
by five inches in size and filling it one-half 



124 Earache 

full with salt. The bag and contents are 
then pressed flat, heated, and applied to the 
ear, the salt retaining the heat for a long 
time. Another device is to fill the finger of 
an old glove with salt, heat it, and place the 
tip in the ear. As an extra precaution the 
mother or nurse should first test it in her own 
ear. A douche at no° F. may also be of 
considerable service in these cases; in my 
experience, earache is best relieved by this 
means. The child should be pinned in a 
sheet, and lie on its back, with its head on a 
level with or a little lower than the body. 
A basin protected with a towel or absorbent 
cotton is placed under the ear. One assist- 
ant is required to steady the head, as the 
child will be sure to struggle. The douche 
bag — an ordinary fountain syringe — should 
be held not more than two feet above the 
child's head. Prom one to two pints of water 
may be needed. The tip of the syringe is 
placed about one-quarter of an inch from the 
orifice of the canal and the water is allowed 
to flow into the ear until the child is relieved 
or until the bag is empty. Such a douche 
may be repeated every hour until medical 
aid arrives. 



Care of the Eyes 125 

Earache is usually due to the presence of 
pus or other fluid behind the drum mem- 
brane. This causes pressure within the ear 
which may require a slight operation for its 
relief. 

THE CARE OF THE EYES 

The eyes should always be well protected 
from the sunlight, the young infant never 
being allowed to lie with a bright light from 
a window streaming into its face. 

The eyes should be washed once daily with 
plain boiled water. A piece of soft old linen 
should be used and immediately burned. 
Before touching the eyes for any purpose, 
the hands must be washed with hot water 
and soap. 

No other home treatment of the eyes is 
allowable, however slight the ailment. The 
custom of putting breast-milk into the 
eyes cannot be too strongly condemned. 
Teas of various kinds and proprietary 
or home-made eye-washes should never 
be used. Over 90 per cent, of the cases 
of blindness develop during early life, nearly 
all being due to neglect or bad manage- 
ment. 



126 Dentition 

DENTITION 

Much has been written about the process 
of teething. Nearly all the ills of childhood, 
other than the contagious diseases, have been 
attributed to this cause. Not only the laity, 
but physicians, are often inclined to attribute 
this or that ailment to teething. Many a 
diagnostic puzzle has been smothered under 
the diagnosis of dentition. Observations 
covering the teething period of several thou- 
sand children in institution, out-patient, 
and private work, among all classes and 
conditions of children, have taught me to 
divide teething babies into three groups: the 
breast-fed, the well-managed bottle-fed, the 
badly fed. 

The breast-fed. — In the great majority of 
the breast-fed, the teeth appeared at the 
proper time, with little or no disturbance. 
Perhaps there was a period of irritability and 
restlessness for a few days before the teeth 
came through. In many, the teeth appeared 
without the slightest inconvenience, and 
that a tooth had been cut was discovered 
while washing or dressing the baby. In a 
very few breast-fed babies there were distinct 



Dentition 127 

irritability and restlessness, with fever and a 
slight diarrhoea, all of which subsided when 
the teeth appeared. 

The well-managed bottle-fed, such as were 
given cows' milk and cream, properly pre- 
pared and diluted, teethed, as a rule, without 
inconvenience. Some showed a tendency 
to slight gastro-intestinal disturbance, which 
was relieved by diet and simple medication. 
The cases which occasionally developed 
severe intestinal disturbances were those 
which cut the first molars or several other 
teeth at one time during the hot weather. 
Such infants must be kept on a very light 
diet until the teeth are through, or until the 
onset of colder weather. 

The badly fed. — These were nearly all 
bottle-fed. They were given cows' milk 
improperly prepared or at too frequent inter- 
vals. Only condensed milk and the pro- 
prietary foods had been given some of these 
infants. To this class belong the great num- 
ber of infants who are given bread, meat, 
potatoes, and sweets before the digestive 
organs are ready for such food. It is these 
badly fed, debilitated, rachitic infants who 
are said to " teeth hard." They teeth late, 



. i8 



I >entition 



( ut :<\ ri.il livl h .1! < hit I inir, atld h.l \r 6t1 
taCkl Oi D hivuImoii;:. . I1.11 1 Inr.i, .111J \ 0111 

tting during Mir teething period, There 
no doubl thai the alimenta: y I rad la pre* 
disp< >sed to t roubles ol g catai i hal na1 ure 
during active dentition, n the i>;ii>v has 
been propei Ly fed and La in fail healthi this 
tendency is .••<> slighl I ha1 ii probably will i»<»i 
be 1 1 * »i iced [f, on the other hand, I he dig 
1 ive I rad is weakened from abuse, vomil ing 
and diai i hoes oi ten resull The ma joi ii\ <>i 
children w I h > belong to the third group are 
rachil ic, and i ickets always mean enfeebled 
resisl m;; powei : ; . Rachil ic children 1 1 u t h 
late, A rachil ic I >oy under my observal ion 
mi his Rrs1 tooth during the ninth month, 
and with the r\ n|»i ion oi I his tooth and with 
each oi the ii\ < v thai appeared a1 intervals oi 
two or three weeks during the next five 
moni hs, .in a1 1 acli oi \ omit ing and diai i hoes 
occurred, each attach subsiding when the 
tooth pierced the gum, 

1 1 1 itabilil \ and resl lessness, slighl fever 
.nni gasl ro intesl ina] derangements, wore 
the only unpleasant effects o( denl it ion in 
any oi my pal ients who were in fair healthi 
The irritability, restlessness, and fever ap« 



Dentition 129 

peared to be due directly to dentition. Indi- 
rectly, teething may be a factor in gastro- 
intestinal derangements. The process may 
be painful, the digestive organs fail to act 
properly, and trouble follows. I have never 
known dentition to cause bronchitis, eczema, 
or skin eruptions of any kind. 

The opinion is very general among the 
ignorant, that bronchitis needs no treatment, 
and that diarrhoea is beneficial during the 
teething process. These beliefs, equally 
dangerous, have been the cause of an incal- 
culable amount of harm: as the result, many 
lives are lost yearly. I have time and again 
seen children die with summer diarrhoea who 
were brought for treatment when no hope 
could be given. The mother had been told 
and believed that diarrhoea was beneficial 
to the teething child, and that if the diarrhoea 
were stopped the child would be thrown into 
convulsions. 

When the form of a tooth can be made 
out pressing on the gum, and the child is 
fretful and feverish, the digestive capacity 
is lessened, as previously mentioned. When 
such is the case the nourishment should be 
temporarily reduced one-half by the addition 



130 The Teeth 

of boiled water. If the child is breast-fed, 
the nursing period should be reduced to five 
or six minutes, and boiled water given to 
drink between feedings. If a tooth is trying 
to force its way through a thick, resistant 
gum, a great deal of pain and discomfort 
will be spared the child if the tooth is assisted 
in its progress. This is best accomplished 
by the use of a clean towel, which is 
placed over the finger and vigorous fric- 
tion brought to bear over the sharp edge of 
the tooth. It is quicker and less painful 
than lancing, and the gum will not close over 
the tooth. 

THE TEETH 

Twenty teeth comprise the first set. In 
the well child the first tooth usually appears 
between the sixth and the eighth months; 
the first teeth may, however, in perfectly 
normal cases, come earlier or much later. 
I have known well, vigorous children who did 
not get a tooth until the thirteenth month. 
The first teeth are usually the two lower 
central incisors; generally the four upper 
incisors and the two lower lateral incisors 



The Teeth 131 

appear between the eighth and the tenth 
months. The first four molars appear be- 
tween the twelfth and the fifteenth months ; 
the eye- and stomach-teeth between the 
eighteenth and the twenty-fourth months; 
the four posterior molars between the twenty- 
fourth and the thirtieth months. This regu- 
larity in the appearance of the teeth is by no 
means constant even in well children. I 
have in several instances seen the upper 
lateral incisors appear first. In delayed 
dentition the teeth are very apt to appear 
irregularly. 

The care of the teeth. — As soon as the teeth 
appear they require attention. Until the 
second year is reached the mouth should be 
washed out at least twice a day with a solu- 
tion of boracic acid — one ounce to a pint of 
water. This can best be done by means 
of absorbent cotton wound around the tip of 
a clean index finger and afterward dipped 
into the solution, when it should be applied 
with gentle friction to the gums and teeth. 
When a child is two years old it is well to 
begin the use of a soft tooth-brush, and a 
simple tooth powder composed of the follow- 
ing ingredients : 



13 2 The Teeth 

Precipitated chalk, i ounce. 
Bicarbonate of soda, i drachm. 
Oil of wintergreen, a few drops. 

The child should also be instructed 
early as to the proper use of a quill tooth- 
pick. 

The milk-teeth are lost between the sixth 
and eighth years. They should not decay 
but fall out or be forced out by the second 
set. The teeth of every child over two years 
of age should be examined by a dentist every 
six months. If cavities are discovered in 
the first teeth they should be filled with a 
soft filling. 

The permanent teeth. — The permanent set 
comprises thirty-two teeth. The second 
dentition begins about the sixth year, and is 
usually completed about the twentieth year, 
although it may be delayed several years 
later. The permanent teeth appear in some- 
what the following order: 

First molars sixth year . 

Central incisors. . . .sixth to seventh year. 
Lateral incisors. . . .seventh to eighth year. 

First bicuspids ninth to tenth year. 

Second bicuspids . . ninth to tenth year. 



The Hair 133 

Canines eleventh to twelfth year. 

Second molars thirteenth to fifteenth year. 

Third molars after the eighteenth year. 

THE HAIR 

Whether the child should wear the hair 
long or short is a point upon which the doctor 
is likely to give unsought advice. There are 
two reasons why a child's hair should be kept 
short : 

1. From the standpoint of comfort. Dur- 
ing the hot months children perspire very 
freely both by day and by night. The heavy 
mass of hair which falls about the neck and 
shoulders adds greatly to the warmth and 
discomfort. I find that many children with 
long hair are poor sleepers and are irritable 
and hard to please when awake. In winter 
the child is very apt to perspire about the 
head and neck in active play, and runs a 
greater risk from exposure than if the exces- 
sive perspiration did not occur. 

2. The hair should be kept reasonably 
short, because then the scalp can be kept 
in a much healthier condition, and a 
much better growth of hair assured in later 
life. 



134 Nursery-Maids 

NURSERY-MAIDS 

The mother who can afford the expense 
of a helper should never take entire charge 
of her baby ; nor should she share this duty 
with the maid of all work if better assistance 
can be secured. The child requires more 
attention than any one person should bestow. 
If one person is constantly in charge of a 
child it will either be neglected or the health 
of the mother or nurse will suffer and conse- 
quently her services be less efficient. Many 
a young mother has sacrificed her health 
because of a false sense of duty in this respect. 
The close confinement in itself would ruin 
her health and make her prematurely old. 
The children that are born later have less 
vigor, are more susceptible to illness, and 
start out handicapped in life as a conse- 
quence. The constant attention of the 
mother is not necessary; in fact, it is often 
injurious to the child. She is apt to handle 
the child too much, to overentertain it. A 
bright young woman should be secured as 
soon as the monthly nurse leaves, to as- 
sist in the care of the child. If she is a 
trained nursery-maid who has had previous 



The Trained Nurse 135 

experience of the right kind, she will be 
invaluable. In case a trained assistant is 
not to be obtained, any intelligent young 
woman of cleanly habits, and who is fond 
of children, may be trained at home in a 
few weeks. 

THE TRAINED NURSE 

If possible, a trained nurse should be em- 
ployed in every severe illness of childhood. 
She may alternate with the mother or nursery- 
maid in the care of the child. If the case is 
very urgent, two trained nurses should be 
employed. The nurse must never be ex- 
pected to work for more than twelve con- 
secutive hours. A tired nurse should never 
be in charge of a sick baby. 

The employment of a trained nurse does 
not mean that the mother may not perform 
many little offices for the patient, but the 
trained nurse should be in charge, and her 
opinions respected. 

Many an excellent mother makes a very 
poor nurse for her own child during a severe 
illness. Her great interest and anxiety 
impairs her judgment. She is apt to become 
confused and fail to meet emergencies. A 



136 The Trained Nurse 

mother who is useless for a like office in her 
own household oftentimes makes an excel- 
lent nurse for her friend's child. The mother 
in the capacity of a nurse for her own infant 
is apt to fail under some of the following 
conditions : She is inclined to put more cloth- 
ing on the baby than the doctor advised. If 
a window is the means of ventilation, she has 
a strong inclination to close it a little beyond 
the point which the physician marked with 
a lead-pencil. The temperature of the sick- 
room is often kept higher than is good for 
the baby. Offices, the performance of which 
cause the child discomfort, are often not 
thoroughly attended to, such as washing the 
eyes, sponging off the patient in fever, syring- 
ing the ears, and adhering to a greatly re- 
stricted diet. These, and a few like offences, 
are pardonable in the mother, but they show 
us that in a severe illness trained help is indis- 
pensable. Further, I am very sorry to say 
that sometimes influences against carrying 
out the physician's directions in important 
particulars are successfully brought to bear 
upon the mother by well-meaning relatives 
and friends who possess no knowledge what- 
ever of the illness in question. 



Adenoids 137 

ADENOIDS 

Adenoids are tumor-like growths that 
develop at the junction of the upper portion 
of the posterior pharyngeal wall and the 
vault of the pharynx. They may simply 
cover the surface of the parts in a spongy 
layer or they may fill the entire nasopharyn- 
geal space, completely blocking the passage 
from the nose to the throat. They are not 
to be considered as new growths, but rather 
as hypertrophies, or overgrowths, of the 
mucous glands and tissues of the parts. They 
may van- in size from a flaxseed to a walnut. 
Among the causes of adenoids may be men- 
tioned the use of the ''pacifier'' in infancy, 
repeated "colds" in the head, breathing 
the dust -laden air of our large cities, mal- 
nutrition, and unhygienic living. While 
the taking of cold is a factor in the de- 
velopment of adenoids, my observation 
is that predisposition plays an important 
part. Many children have a tendency to 
glandular enlargement ; in fact, in Xew York 
City, a large percentage of the children under 
ten years of age have adenoids. In a child 
under two years of age the nasopharyngeal 



138 Adenoids 

space is a very narrow slit; and since the 
majority of children up to the eighteenth 
month of life are sucking on something the 
greater part of their waking hours, the soft 
palate is forced back against the posterior 
pharyngeal wall, interfering with the drain- 
age of the parts, and on account of the fric- 
tion of the opposed surfaces congestion and 
irritation follow, resulting finally in a general 
hypertrophy. 

Very young children may have adenoids. 
The youngest patient that I have operated 
upon was eight months old. The majority 
of cases occur in children from eighteen 
months to six years of age. A slight amount 
of adenoid growth may cause no symptoms. 
A few summers ago I examined the throats 
of forty children between the ages of two and 
five years, who came for treatment for other 
conditions. In thirty-seven, adenoids were 
present. In twelve, operation was advised, 
and in five, operation was performed. In 
fifteen the growths were not sufficiently large 
to justify operation in the absence of annoy- 
ing or dangerous symptoms. 

The presence of adenoids is perhaps most 
often manifested by symptoms of chronic 



Adenoids 139 

cold in the head. There is a great deal of 
discharge from the nose. The child has 
snuffles all winter. During summer there is 
little if any trouble. The child is said to 
take cold easily. The slightest exposure 
will cause a running at the nose. Cough is 
often associated with the nasal discharge, 
or it may follow it. The cough is worse at 
night; in fact, it often is not noticed until 
the child goes to bed. Such a cough was 
formerly known as "the nervous cough" or 
"the stomach cough." 

If the growths are large, we have mouth- 
breathing added to the other symptoms. 
The child breathes through the mouth both 
day and night for the reason that the breath- 
ing space through the nose is choked. The 
night mouth-breathing gives rise to snoring; 
some of these children snore like adults. 
Almost every snoring child will be found 
to have either adenoids or enlarged tonsils, 
or both. 

In advanced cases the appearance of the 
face of the patient is characteristic. The 
habitual open mouth gives the face a stupid 
expression. In fact, such children are apt 
to be mentallv dull. The nostrils are small 



140 Enlarged Tonsils 

and pinched. The upper lip is usually thick- 
ened. The voice is also affected; there is a 
decided nasal twang, and articulation is 
sometimes impaired. The child has trouble 
in blowing his nose. Occasionally adenoids 
are the cause of very severe nosebleed. In 
a small proportion of the cases hearing is 
impaired. Bed-wetting may be due to ade- 
noids. Recently a writer reported seven 
cases of inveterate bed-w^etters, all cured by 
the removal of the adenoids. These children 
are more susceptible to diphtheria, and if 
they contract the disease it is apt to be more 
severe. For adenoids of any degree of sever- 
ity, complete removal is the only treatment. 
Sprays and the various local applications are 
absolutely worthless. The operation is prac- 
tically without danger. 

ENLARGED TONSILS 

Chronic enlargement of the tonsils is almost 
always associated with adenoids and is re- 
sponsible in a degree for their presence. We 
see many cases of adenoids, however, in 
which there is no tonsillar enlargement. 
Predisposition and repeated attacks of acute 
tonsillitis lead to chronic enlargement of the 



Milk in Infants' Breasts 141 

tonsils. Enlarged tonsils, when associated 
with adenoids, do not change the character 
of the symptoms of adenoids except to aggra- 
vate them ; therefore they should be removed 
as well as the adenoids. All other treatment 
in young children is useless. The operation 
in skilful hands may be said to be practically 
without danger. Parents always dread the 
operation, but the relief afforded the suffering 
child, and the knowledge that a serious ob- 
stacle to the child's growth and development 
has been removed, will repay them for their 
hours of anxiety. Gargles and sprays are of 
little or no value in chronic enlargement of 
the tonsils. 

MILK IN INFANTS' BREASTS 

It is not at all uncommon for an infant's 
breasts, at birth, to contain a substance 
resembling milk. When this occurs, the 
breasts are to be left alone and the milk will 
disappear. It is quite a common belief 
among hospital and dispensary patients that 
the milk should be pressed out. This is very 
wrong. In two cases I have known abscesses 
to develop after this treatment by a midwife, 
and in one case the child nearly lost its life. 



142 How to Take Temperature 

TEMPERATURE, AND HOW TO TAKE IT 

The normal rectal temperature of an infant 
varies between 98.5 and 99. 5 F. The tem- 
perature should be taken in the rectum. The 
mouth is impossible, the groin and axilla 
absolutely unreliable. The child should lie 
on its stomach either in its bed or across the 
nurse's lap. Both the anus and the bulb of 
the thermometer should be well oiled. The 
bulb is passed into the rectum so that the 
mercury cannot be seen and allowed to remain 
three minutes. If the child kicks or struggles 
some one should hold its legs. Mothers are 
often disturbed because of a persistence of 
the temperature between 99. 5 ° and 100. 5 ° F. 
While such a degree cannot be considered 
normal, it does not follow that it is of any 
consequence. This slight elevation may 
follow the acute illnesses such as grippe, 
pneumonia, and scarlet fever, and may con- 
tinue for weeks, without any harm resulting. 
Nervous, irritable infants will often range 
at ioo° F. for weeks at a time. In like 
'manner children who are stimulated by 
playing with older children or with adults 
will often develop a rise in temperature 



Appetite 143 

which subsides as soon as the cause is re- 
moved. 

The thermometer should be washed with 
a one-per-cent solution of carbolic acid after 
using. 

APPETITE 

It may be safely said that a well, vigorous 
child is a hungry child, and nearly every 
child may be made thoroughly hungry three 
times a day by suitable food at proper in- 
tervals. The children who come under my 
care for poor appetite, without evidence of 
disease to account for it, are, almost without 
exception, improperly fed. They are often 
given unsuitable food at meal-time, when 
they are loaded down with sweets and pas- 
tries; but the chief error is eating between 
meals. This habit has ruined more appe- 
tites and has been the cause of more stomach 
disorders than any other one factor. It is 
surprising what a large amount of candy, 
sweet crackers, and the like are disposed of 
in many households. Every year I am called 
upon to treat cases of loss of appetite in " run- 
abouts" from eighteen months to three years 



144 Appetite 

of age, who have what I have designated the 
milk habit. These children drink from five 
to six pints of milk a day, and refuse all other 
food. The milk satisfies the appetite but 
does not furnish the nourishment required 
for the rapid growth that takes place at this 
time, and the child in consequence suffers 
from malnutrition. He is pale, thin, and 
sallow in appearance, the sleep is poor, and 
the child is irritable and hard to please. We 
also see children at this age who suffer from 
improper nutrition on account of too re- 
stricted a diet. They take other food than 
milk, but not in sufficient quantity or variety. 
Some will refuse all kinds of vegetables, 
others will refuse all kinds but one or two; 
some will not take stewed fruit ; others will 
not touch meat or eggs, no matter how they 
may be prepared; some will take but one 
cereal, others will refuse cereals altogether. 
The child's whims in these respects must 
never be catered to. He is to take what is 
placed before him or go without until the 
next meal. Likes and dislikes for various 
articles of diet are largely a matter of edu- 
cation, and the child may, and should, be 
taught to eat everything that is good for 



Appetite 145 

him. A little firmness in compelling him 
to go hungry for a few hours will soon do 
away with any childish fancy, which may 
be the cause of considerable harm. These 
children are rapidly growing, and for proper 
growth and development require a mixed 
diet. If the child is wedded to milk and 
refuses everything else, the milk must tem- 
porarily be discontinued. Some children 
with a poor appetite for solids will drink a 
glass or two of milk at the commencement 
of a meal. This satisfies the appetite for the 
time and nothing more will be taken. With 
such children the milk must be kept out of 
sight until the meal is completed, when one- 
half pint may be given. 

I have treated quite a number of cases of 
poor appetite and milk appetite in children 
otherwise well, in the following manner: 
The child is undressed and placed in bed 
and put under the care of one person as 
though he were very ill. The object in 
placing the patient in bed is to prevent his 
getting food other than that ordered. He 
is allowed water to drink in plenty. For 
the first day he is given four ounces of plain 
chicken or mutton broth every three hours. 



146 Appetite 

The second day he receives six to eight ounces 
of the broth at three-hour intervals. On 
the third day he is usually ravenously hun- 
gry and he is then given three or four good 
meals, when, if he has any special dislike 
for any article of diet, that is included in 
the first meal. In such cases it is surprising 
with what favor the formerly despised cereal, 
meat, egg, or vegetable will be looked upon, 
and it will thereafter have a cherished place 
in the child's heart. Some mothers will not 
be a party to such heartless treatment, as 
they are inclined to call it, but this is a wrong 
view to take of it. A complete change of 
diet for a day or two would often be of benefit 
to all of us. With the child the advantage 
derived from thus learning to enjoy a mixed 
diet will favorably influence his health for 
the rest of his life. Change of climate, fresh 
air, out-of-door exercise, suitable food at 
regular intervals — all favorably affect the 
appetite. 

Children who over-exert themselves at 
school or at play or who are easily excited 
and have plenty of opportunity for excite- 
ment often suffer from loss of appetite. The 
management of these cases is to remove the 



Habits 147 

source of the trouble, whatever it may be. 
An excellent means of bringing these chil- 
dren to a normal condition is an enforced 
rest for one and one-half hours after the 
noon-day meal. 

HABITS 

The Pacifier; Ear-Pulling; Masturbation 

Babies acquire habits most easily and at 
a very early age. Whether the habits are 
good or bad depends more upon the child's 
attendants than upon the child itself. If 
properly trained — and the training must 
begin at birth — a baby will acquire the habit 
of taking his food at regular intervals by day 
and by night, and he will also acquire the 
habit of going to sleep and waking at regular 
intervals. As a result of a careful regime 
regarding feeding, sleep, bathing, and airing, 
and the performance of its various functions 
at stated times every day, the baby will soon 
develop into a " little machine,' ' as one 
mother called her babe. Such a child causes 
no trouble and thrives far better than one 
who is fed every time he cries, day or night. 
A baby that requires constant entertaining 



148 Habits 

when awake, and that sleeps only when ex- 
hausted, usually has another bad habit, — 
that of being held constantly in arms. A 
baby should be handled very little, — just 
enough to give it exercise. It will learn to 
amuse itself at a very early age if given an 
opportunity. 

The "pacifier" habit — the habit of sucking 
a rubber nipple — is an inexcusable piece of 
folly for which the mother or nurse is directly 
responsible. The habit when formed is 
most difficult to give up. The use of the 
' ' pacifier, ' ' thumb-sucking, finger-sucking, 
etc., make thick, boggy lips, on account of 
the exercise to which the parts are subjected. 
They cause an outward bulging of the teeth 
and a narrowing of the jaws, which are not 
conducive to personal attractiveness. Nature 
has not been so lavish of her gifts to the great 
majority of mankind that they can afford 
to trifle with her handiwork. Furthermore, 
the " pacifier' ' is often a menace to health. 
If there are two or three young children in 
the family it is frequently passed around 
without other means of cleansing than being 
drawn a couple of times across the nurse's 
sleeve. This novel method of disinfecting 



Habits 149 

the "pacifier" may be seen in actual use in 
the Park any pleasant day, and I have often 
seen the mother or nurse moisten the " paci- 
fier" with her own lips before giving it to 
the child. I have seen young children fight 
for the "pacifier," one taking it from the 
mouth of another! It may readily be con- 
ceived what a boundless source of harm this 
little instrument may be, when every sort 
of disease known to childhood may be trans- 
ferred by it. Thus it may act as a means of 
transmitting tuberculosis, syphilis, diphtheria 
and many other ailmentsof minor importance. 

Adenoids, referred to in another chapter, 
are often the result of thumb-sucking or the 
use of the "pacifier." The pressure exerted 
in sucking forces the soft palate against the 
posterior pharyngeal wall; this irritates and 
stimulates the glands of the part, which in 
time enlarge, and adenoids develop. 

To break the child of the "pacifier" habit, 
burn the "pacifier" and do not buy another, 
as is sometimes done. For thumb-sucking and 
finger-sucking, bandage the hands and moisten 
the bandage occasionally with a solution of 
quinine. The "hand and hold mit " (Fig. 00) 
is a useful means in breaking the habit. 



150 Habits 

A few children develop the ear-pulling 
habit. It is always one ear which receives 
attention. Sometimes it is the lobe and 
sometimes the upper portion. The child 
pulls on the ear the greater portion of its 
waking hours. As a result of this practice, 
I have seen ears drawn entirely out of shape. 
Bandaging the hands so that the fingers can 
not be used to grasp the ear is the best means 
of breaking the habit. The " hand and hold 
mit" may also be used with advantage. 

Occasionally children are met with who 
have a mania for placing foreign bodies in 
the nose and ear. Shoe buttons are the favor- 
ites, although beans, pieces of' coal, pebbles, 
and various other kinds of buttons serve the 
purpose when shoe buttons are scarce. The 
habit is best controlled by a vigorous spank- 
ing following each offence. 

Masturbation is one of the most injurious 
of habits. It consists in an irritation of the 
genitals by manipulation, by leg-rubbing, or 
by pressing the parts against some pointed 
object. Under the age of six years mas- 
turbation is more common in girls than in 
boys. My youngest was a girl only six 
months old. If the habit is not detected, 



Habits 151 

masturbation may be practised for a long 
time and repeated many times a day. As a 
result, the child becomes irritable, loses sleep 
and weight, and is transformed into a con- 
dition of mental and physical exhaustion. 

The formation of habits and their cor- 
rection rests largely with the mother or 
attendant. Considerable stability is neces- 
sary for the correction of a bad habit, or the 
formation of a good one. It means several 
prolonged crying attacks on the part of the 
child and perhaps two or three wakeful 
nights. To cure the habit of masturbation, 
if the child is under eighteen months of age, 
the hands may be bandaged, or, what is 
better, a piece of tape may be fastened 
around each wrist and tied together at the 
back of the neck, making all secure with a 
safety-pin. The pieces of tape should be 
of sufficient length to allow the child free 
movement of the hands, but not long enough 
to allow them to come in contact with the 
genitals. 

Leg-rubbing is more frequently seen in 
very, young girl babies. In such cases the 
wearing of a thick napkin or of two napkins 
will usually prevent the practice. In some 



152 The Normal Throat 

obstinate cases of leg-rubbing in older girls 
I have used a "knee crutch' ' with decided 
success. In children over two years of age, 
constant watchfulness and vigorous pun- 
ishment for each offence, combined with 
medical treatment, will cure most cases, 
although with some much difficulty will be 
experienced. 

The practice must be prevented and the 
genitals brought to a normal condition, when 
the patient will soon forget the indulgence. 

THE NORMAL THROAT 

Every mother should learn the appearance 
of the healthy throat, and every child should 
be accustomed to throat examination. It 
will soon learn that no harm is intended and 
force will not be required. The family phy- 
sician should demonstrate to the mother the 
color of the normal mucous membrane, and 
the size and appearance of the tonsils in 
health. By knowing the normal throat she 
will be able to recognize inflammation, swel- 
ling, and exudation in the form of the cheesy 
dots seen in tonsillitis, and the membrane 
in diphtheria. With the first appearance 
of exudation of any kind, medical aid should 



How to Examine the Throat 153 

be summoned. No chances should be taken 
with these cases. I know of fathers and 
mothers who will never cease to regret that 
they did not appreciate the dangers of tem- 
porizing with what they considered a " can- 
kerous sore throat.' ' Diphtheria is most 
insidious in its onset and a sore throat should 
never be neglected. 

HOW TO EXAMINE THE THROAT 
(See Fig. 8.) 

In order to examine a baby's throat quickly 
and thoroughly the child must be held in 
front of and at the right side of the attend- 
ant, supported by the attendant's left arm 
under the buttocks; the right arm, which is 
thus left free, is passed around the child, 
binding its arms to its sides. The child's 
head rests upon the right shoulder of the 
attendant. 

The mother places her left hand on the 
child's head to steady it and with tongue 
depressor or teaspoon in her right hand she 
presses down the tongue, and, with the child 
under perfect control, she brings into view 
the parts that are to be examined. The 



154 Sprue and Thrush 

most satisfactory view can be obtained by 
daylight before a window. If the examina- 
tion is made in the evening, a lamp or taper 




i i 1 

FIG. 8. THE THROAT EXAMINATION 

held by a third party, a trifle above and 
behind the mother's right shoulder, will 
furnish a satisfactory illumination. 

SPRUE AND THRUSH 

Thrush consists of a parasitic growth 
which appears on the mucous membrane 
of the mouth in young infants. The dis- 



Sprue and Thrush 155 

ease makes its appearance in the form 
of small white masses about the size of a 
pinhead. The tongue and the inner side 
of the cheeks are favorite sites for the 
growth, although in severe cases the entire 
buccal cavity may be studded with it, causing 
it to look as though finely curdled milk had 
been scattered over the surface. The growth 
is firmly adherent, and if removed forcibly, 
slight bleeding results. It is usually asso- 
ciated with uncleanliness, and occurs, as a 
rule, in weakly and marasmic nurslings and 
in the bottle-fed, more frequently in the lat- 
ter. It is rarely seen after the sixth month. 

In an infant with sprue, there is evidence 
of much pain and discomfort while nursing 
or while feeding from a bottle. The disease 
is not contagious. The average case may 
easily be cured in a week, if the directions 
for the treatment are carefully carried out. 
Active gastro -enteric disturbances, such as 
vomiting and diarrhoea, may be associated 
with sprue, but it is not the rule. Time and 
again I have seen cases of sprue in which 
there were absolutely no other signs of the 
disease aside from the characteristic mouth 
lesions and the refusal of food. 



156 Sprue and Thrush 

If the means of prophylaxis, which will be 
suggested, are used as the daily routine, the 
disease will never appear. 

If breast-fed, the mother's nipples must 
be washed with a saturated solution of boric 
acid, and moistened with alcohol, diluted 
one-half, which is allowed to evaporate before 
each nursing. If bottle-fed, the nipple and 
bottle should be boiled after each nursing, 
the nipples turned inside out and scrubbed 
with borax water — one ounce of borax to a 
pint of water. Whether breast-fed or bottle- 
fed, the mouth should be washed with a 
saturated solution of boric acid after each 
nursing. For this purpose a generous 
amount of absorbent cotton is loosely 
wrapped around the clean index-finger of 
the mother or nurse. This is placed in the 
cold solution, and without pressing out the 
water the finger is introduced into the child's 
mouth, and, in cases of sprue, brought gently 
in contact with the diseased parts, first with 
one side and then with the other, being 
pressed upon the tongue and under the 
tongue. It is well to have the child rest 
on its side or stomach so that the fluid which 
is pressed out by the manipulation of the 



Stomatitis, or Sore Mouth 157 

cotton against the cheeks and jaws can 
readily escape from the mouth. The wash- 
ing, which really amounts to an irrigation, 
can be done in a few seconds, without the 
slightest danger of abrading the epithelium. 
Internal medication is of no value in sprue 
except in correcting any intestinal derange- 
ment that may exist, with a view to improv- 
ing the general condition. If the bottle 
or breast is refused, spoon-feeding for a few 
days may be necessary, and will hasten a 
cure. If the child is nursed, the mother's 
milk may be drawn with a breast -pump 
(see page 47), or pressed out with the fingers, 
and fed to the child. The domestic remedy, 
honey and borax, should not be used in any 
of the inflammatory diseases of the mouth 
in children. 

STOMATITIS, OR SORE MOUTH 

There are three varieties of this disorder — 
the catarrhal, the aphthous, and the ulcerative. 

In the catarrhal form there is redness 
of the gums with excessive secretion of 
saliva. 

In aphthous stomatitis, distinct grayish- 



158 Stomatitis, or Sore Mouth 

white plaques will be noticed on the inner 
side of the cheek and under surface of the 
tongue, varying in size from a pin-head to 
a split pea. 

Ulcerative stomatitis is the most serious 
disease of the three. It may occur during 
serious illness, but in most instances it occurs 
independently. There is a general con- 
gestion of the mucous membrane with the 
secretion of a great deal of saliva. Its dis- 
tinguishing point, however, is the line of 
ulceration which forms on the border of the 
gum at its junction with the teeth. The 
ulceration may be so severe as to cause a 
loosening and falling out of the teeth. The 
breath is often very foul, and the gums bleed 
at the slightest touch. 

Lack of cleanliness plays a large part in 
causing sore mouth. Unclean feeding appa- 
ratus, the use of the " pacifier, " and the 
custom of allowing a baby to put into its 
mouth everything within reach account for 
a majority of the cases. 

The symptoms are fever, loss of appetite, 
and evidences of much discomfort when the 
child attempts to eat. In many cases of 
the ulcerative form there are high fever and 



Taking Cold 159 

greater prostration than one would think 
possible. 

The prevention and treatment are the 
same — cleanliness. The sore mouth should 
be washed with a saturated solution of boric 
acid after each feeding, using absorbent 
cotton, which is wrapped around the index 
finger. The cotton is saturated with the 
solution and gently brought into contact 
with the diseased surface. Force must not 
be used in these cases, as more damage than 
benefit will result if the tissues are lacerated. 
In the ulcerative form internal treatment is 
required in addition to the local means sug- 
gested. Every case of ulcerative stomatitis 
should be seen, at least once, by a physician. 

TAKING COLD 

By ''taking cold" we understand that 
through the influence of cold upon some 
portion of the skin an impression similar in 
nature to that of shock is produced, which 
affects the entire body and manifests itself 
most frequently in the form of a congestion 
of the mucous membrane of the respiratory 
tract, between which and the skin there 



160 Taking Cold 

seems to be an intimate connection. Micro- 
organisms play an important role in the 
process. They are found in large numbers 
on the diseased mucous surfaces. The 
changes in the mucous membrane resulting 
from the exposure prepare the parts for 
their growth and development. The taking 
of cold means previous exposure, and what 
will constitute a sufficient degree of exposure 
in one individual may produce no effect in 
another. According to my observation, the 
most frequent cause of colds in infancy is 
the action of cold air on a moist skin. The 
child that perspires readily, or the child 
that is made to perspire by unsuitable cloth- 
ing, suffers most in this respsct during the 
cold season. I look upon inadequate head- 
covering as a most frequent cause of diseases 
of the respiratory tract in the young. Most 
infants are dressed for the daily outing in a 
warm room, with the temperature ranging 
from 75° to 85 . The child is wrapped in 
ample coats, blankets, and leggings; he is 
active, throws his legs and arms about j the 
dressing thus far requires quite a period of 
time he perspires freely, but the dressing 
is not completed. On the head is placed 



Taking C 

one of the more or less artistically decorated 
airy creations which are sold in the shops 
as children's caps. They furnish little pro- 
tection for the many square inches of the 
almost bald little head. The child is take- 
out of doors; a wind is blowing; the result 
is a cold, and how it came about is never 
understood. He was supposed to be dressed 
ideally for cold weather. The idea is com- 
mon and to a certain degree proper that a 
chili's head sh:uli :e he::: c::l. This 
theory, however, gives rise to carelessness 
as to the head-dress. During the colder 
months I advise mothers to make a skull-cap 
out of thin flannel, which the child can 
wear under the regular outing cap. 

Allowing a child to sit on the floor during 
the winter months is probably the next most 
frequent cause of taking cold. Kicking off 
the bedclothes at night is another frequent 
cause. Taking the child from a warm room 
through a cold hall is not without danger. 
Holding the child for a few moments by an 
open window during the cold weather is 
often followed by croup, bronchitis, and 
pneumonia. The uneven temperature : 
the living- and sleeping-rooms in many of 



162 Taking Cold 

our New York apartments is a very frequent 
cause of cold. Frequently during the day the 
temperature will be between 75 and 8o°, but 
at night, when the fires are banked, it falls to 
55 or 6o° or lower. The child went to bed 
warm and perspiring, kicked off the bed- 
clothes, the temperature in the room fell, the 
body became chilled, and the child took cold. 

Among rachitic children there is a marked 
predisposition to catarrhal affections ; they 
acquire laryngitis and bronchitis upon very 
slight provocation. 

In many instances colds in infants are 
attributed to the bath. Among dispensary 
mothers this is often considered a cause of 
cold. I have never known a cold to be due 
to a bath. 

Adults and " runabout " children with 
coughs and colds should not come in contact 
with infants. There is undoubtedly an 
element of contagion in such cases. It is 
a very bad practice to have a family pocket- 
handkerchief. The youngest infant is en- 
titled to a handkerchief independent of the 
other children, and a handkerchief should 
never do service for more than one indi- 
vidual between washings. 



Cough 163 

Mothers can do little without medical aid 
in the treatment of colds, but they can do 
much in preventing them. The tempera- 
ture of the living-room should range from 
70 to 72°F., the sleeping-room from 6o° to 
66° F. Of course it will be impossible to 
keep the temperature at all times at these 
figures, but the closer it approximates to 
them the safer the child will be. 

Children must not be allowed to sit on the 
floor during the winter. They can have 
their playthings on the bed, on the sofa, or 
in a clothes-basket, which may be raised on 
two thick pieces of wood or a couple of books. 
There is always a draught near the floor. 
The "pen" referred to on page 321, is the 
best scheme that I know of for keeping 
children from the floor. 

The room in which the child is dressed 
for an outing should not be above 70 F. 
Securely pinning bed -blankets to the mat- 
tress, or, better, a combination suit with 
"feet" will do much to prevent the child 
from taking cold at night. 

COUGH 

The most frequent cause of the temporary 



1 64 Cough 

cough seen daily in children's work is almost 
always an acute inflammatory condition of 
the mucous membrane of the respiratory 
tract, involving usually the fauces, the 
larynx, and bronchi, subjects which are 
referred to under their respective headings. 
Chronic cough. — Ninety-five per cent, of 
the obscure coughs are due to adenoid vege- 
tations in the naso-pharyngeal vault. In- 
cipient tuberculous infiltration in any portion 
of the lungs or pleura may produce the per- 
sistent cough. Thorough physical exami- 
nations and careful observation of the case 
for a few days will make a diagnosis possible. 
Whooping-cough without the w T hoop or 
vomiting may cause a persistent cough. It 
runs its course and subsides in from four to 
eight weeks. A diagnosis of such mild cases 
of whooping-cough is possible only when 
there is a history of exposure to the disease. 
I have had occasion to examine and treat 
many children who were brought to me 
because of a " cough/ ' which had not been 
controlled by the measures employed. While 
we hear much of the cough of teething, the 
" stomach cough," the "nervous cough," 
and the "habit cough," it has never been 



Cough 165 

my lot to see a case in which the cough was 
not connected in some way with the respira- 
tory tract. Thorough examination of these 
cases, perhaps repeated examinations, will 
be required before the site of the trouble is 
definitely located, when it will almost in- 
variably be found somewhere in the respira- 
tory tract. The stomach cough, the nervous 
cough, and the teething cough formerly stood 
for the persistent cough which could not be 
accounted for by physical examination of 
the chest or by mere inspection of the throat. 
They are frequently referred to by the older 
writers. An elongated uvula, to which these 
obscure coughs have also been attributed, is 
very rarely a cause. The history is usually 
only that of a persistent cough. It may be 
irritating in character, keeping the child 
awake at night, or it may be paroxysmal, 
the attacks being more severe when the child 
is lying down. Many times the paroxysms 
are so severe, being particularly worse at 
night, that whooping-cough is suspected be- 
cause of the absence of chest signs. 

An immense majority of these obscure 
coughs in children are due to adenoid vegeta- 
tions with or without enlarged tonsils. A child 



1 66 Cough 

with such a cough may have the typical ade- 
noid face, mouth -breathing, and other signs 
referred to (see Adenoids, page 137), or these 
symptoms may be entirely absent. It is 
the latter type of case that is particularly 
puzzling and apt to be overlooked. On 
account of the absence of mouth -breathing 
and other symptoms of nasal obstruction, 
the possibility of adenoid vegetations has 
been ignored. In these cases careful inquiry 
will usually elicit the history of frequent 
colds, or what is styled " catarrh," as there 
is more or less serous discharge from the 
nose, or the child is said to "take cold in 
the head easily." Digital examination of the 
naso-pharyngeal vault will reveal a fringe 
of soft adenoid growth at the upper portion 
of the posterior pharyngeal wall, not large 
enough to produce obstruction, but actively 
secreting. This secretion, if not profuse, 
is partially evaporated in the nostrils, or if 
profuse, is discharged from the nostrils or 
passes backward over the posterior pharyn- 
geal wall, thus provoking cough, when the 
child is up and about. When the child 
rests on -his back, the secretion naturally 
flows over the posterior pharyngeal wall, 



Cough 167 

and a cough is the result. Time and again 
I have relieved the most obstinate cough 
by curetting and removing this sponge -like 
tissue. In one patient, a boy two years of 
age, who had been coughing hard for ten days 
with paroxysms and vomiting, a diagnosis 
of whooping-cough had been made by a 
member of the family who had seen many 
cases of whooping-cough, and also by myself. 
Adenoids were found to be present in a slight 
degree. Their removal was advised, with 
the idea of making the coughing attacks less 
severe, when, greatly to our surprise, the 
coughing ceased at once, not a paroxysm 
occurring after the growth was removed. 
The cough was due to the adenoid vegeta- 
tions and not to whooping-cough. 

Tracheitis (inflammation of the wind- 
pipe) will produce a cough, severe and in- 
tractable, with no signs in the chest. In 
these cases, however, the cough is usually 
sudden in its development. It is often 
accompanied by slight fever, and if the child 
is old enough he will aid us by referring to 
the sense of discomfort and tightness which 
exists over the upper portion of the chest. 
Sometimes the sensation will be described 



168 Tonsillitis 

as a burning, which is located directly over 
the trachea. 

TONSILLITIS 

Tonsillitis, or inflammation of the tonsils, 
is a very common ailment among children 
during the colder months. It usually fol- 
lows exposure. The onset is generally 
sudden, with high fever, — io3°to 105 F., — 
pain, swelling, headache, and general mus- 
cular soreness. Inspection of the throat 
will show the tonsils to be swollen and in- 
flamed. The entire throat generally has 
a congested appearance. No other changes 
may be noticed. In the majority of cases, 
however, the tonsils will be found studded 
with small white dots of a cheesy material. 
If the case is seen two or three days after 
the beginning of the illness the dots may 
have coalesced, forming large yellowish 
patches which so closely resemble the appear- 
ance of the throat in diphtheria, that it may 
be impossible for the physician without the 
aid of a microscope to differentiate between 
the two diseases. An attack of tonsillitis 
runs its course in from two to five days. 



Cold in the Head 



169 



Cold applications, cold compresses (see cut) 
to the throat, and cold spongings of the 




FIG. 9. COLD COMPRESS 



body afford the patient much relief. A dose 
of castor-oil given at the first symptom of 
the disorder will always be of value. 



COLD IN THE HEAD (CORYZA) 

A cold in the head is a very frequent 
occurrence in the young, and while not 
serious if the trouble limits itself to the 
mucous membrane of the nose, it is, never- 



170 Cold in the Head 

theless, a source of much annoyance to 
both mother and child. The mucous mem- 
brane of the nasal passages is congested 
and swollen. The nostrils of infants in 
health are very narrow, so that a slight 
congestion will greatly interfere with the 
breathing. 

The first sign to be noticed is that when 
the child is nursing he is unable to breathe 
easily through the nose, and frequent rests 
are necessary. Sleep, for this reason, is also 
interfered with. The baby sneezes more 
than usual and there is a watery discharge 
from the nose with usually a degree or two 
of fever. With the onset of the first symp- 
toms, one teaspoon ful of castor-oil will be 
of service. A few drops of melted vaseline 
or liquid alboline may be dropped into the 
nostrils every two hours. 

The danger from a so-called "cold in the 
head " rests in the fact that the inflammation 
does not always limit itself to these parts. 
It is very liable to extend to other portions 
of the respiratory tract, terminating some- 
times, even if properly treated, in bronchitis 
or broncho -pneumonia. 



Bronchitis 171 

BRONCHITIS 

Bronchitis may occur as a primary illness, 
or it may follow a cold in the head, laryn- 
gitis, or any inflammatory condition of the 
respiratory tract. It often occurs as a com- 
plication of other diseases. There is almost 
always more or less bronchitis with measles. 
In bronchitis we have a serious illness not 
necessarily serious in itself but mainly so 
because of the frequency with which it leads 
to catarrhal pneumonia. Bronchitis in a 
delicate child requires but a little bad man- 
agement or neglect and pneumonia will 
surely develop. 

The reason why bronchitis is a dangerous 
illness in a young child is because of the lack 
of development of the parts which form the 
chest walls. The ribs are soft and the mus- 
cles weak. The bronchial tubes collapse 
readily. In an older child the bronchial 
secretions are coughed into the mouth and 
swallowed or expectorated. The young 
infant cannot expectorate. When the secre- 
tion is viscid and thick, the weak chest-wall 
fails to furnish the power required to expel 
it and instead it is drawn deeper into the 



172 Bronchitis 

lungs, the smaller tubes become clogged 
with mucus, the air vesicles collapse, bac- 
teria multiply rapidly in the confined secre- 
tions, and pneumonia results. 

Bronchitis is indicated by coughing and 
wheezing, and w r hat the mother often calls 
"a drawing of the chest/ ' In many cases 
fever is present in a marked degree. The 
severity of the cough and the other symp- 
toms depend entirely upon the severity of 
the lesions. In many cases, if seen early 
the disease will respond to treatment in a 
day or two. A generous counter-irritation 
of the chest with one part of turpentine and 
three parts of camphorated oil is a useful 
measure, the applications to be made twice 
a* day — morning and evening. What is 
better, however, is the use of the mustard 
plaster, made by mixing one part of mustard 
with three parts of flour, sufficient warm 
water being added to make a paste, which 
may be spread on cheese-cloth or thin muslin . 
It should be large enough to encircle the 
chest, fitting the child like a jersey. This 
is covered with another piece of similar 
material and the plaster is complete. It 
should be wrapped around the chest and 



Croup 173 

allowed to remain from ten to fifteen minutes 
— until the skin is thoroughly reddened. 

Proprietary cough mixtures and home 
remedies should never be relied upon for 
the treatment of bronchitis in children. 

CROUP 

CATARRHAL CROUP; DIPHTHERITIC CROUP 

There are two varieties of croup, catarrhal 
and diphtheritic: catarrhal croup is a catarrhal 
inflammation of the larynx, and diphtheritic 
croup a membranous inflammation of the 
larynx. 

Catarrhal croup may begin in two ways. 
The child will suffer from snuffles, indicating 
a simple cold in the head, which is followed 
by a slight fever and a mild cough. The 
cough rapidly becomes worse and is hoarse 
and barking in character, becoming more 
severe toward evening. As a rule, the fever 
is not high. In the evening of the second 
or third day of the illness, sometimes the 
first day, signs of obstruction to the breath- 
ing become apparent. The inspiration is 
labored and accompanied by a croaking 



174 Croup 

sound. The child cannot speak above a 
whisper. 

Probably not over half of the cases show 
this gradual development. In many the on- 
set is sudden : the child goes to bed as well as 
usual; after a quiet sleep of a few hours he 
awakes suddenly, sits up in bed, and with 
high-pitched cough, straining for breath, he 
startles the household. 

Membranous or diphtheritic croup is much 
the more dangerous affection, but to the 
mother there is no means of distinguishing 
between the two forms, unless the child has 
diphtheria and the croup follows. The two 
forms may appear in identically the same 
way, although the onset of the diphtheritic 
croup is usually more gradual. 

In case of a severe cough or a sharp attack 
of croup in one of the children, the mother 
or nurse in charge has three duties to per- 
form: send for the doctor, isolate the child, 
and give him a teaspoon ful of the syrup of 
ipecac, which may be repeated in fifteen 
minutes if there is no vomiting. Every case 
of croup should be quarantined until the 
nature of the trouble is determined. If it 
is catarrhal, no harm will be done by the 



Croup 



i7S 



isolation. If it is diphtheritic, the lives of 
other members of the household may be 
saved by the precaution. If a croup-kettle 




FIG. 10. THE HOLT CROUP-KETTLE 

is at hand (see cut 10), it should be brought 
into use after making a tent by covering or 
draping the crib with a sheet (see cut n). 
One teaspoonful of tincture of benzoin is 



176 



Croup 



added to one quart of water and placed in 
the kettle, which is heated by the alcohol 



41 II 1PB* i. 




FIG. II. CRIB PREPARED FOR STEAM INHALATION 

lamp attachment. A cold compress (page 169) 
applied to the throat is often beneficial also. 



Pneumonia 177 

It should be thoroughly wrung out, covered 
with some dry material, and changed every 
twenty minutes. The child should receive 
a laxative as early as possible in the attack. 

PNEUMONIA 

Pneumonia, sometimes referred to as in- 
flammation of the lungs, or lung fever, 
occurs very frequently in infants and young 
children. It may appear as an independent 
affection or as a complication of other dis- 
eases. There are two varieties which are 
commonly met with in the young: lobar 
pneumonia, which corresponds closely to the 
adult type, and broncho-pneumonia, or, as 
it is sometimes called, catarrhal pneumonia. 

Lobar pneumonia usually results from 
exposure — a sudden chill of some part of the 
surface of the body. 

Broncho -pneumonia is usually the outcome 
of bronchitis or what is known as "a common 
cold." 

The latter is most frequently seen in chil- 
dren and is usually the variety which occurs 
as a complication of other diseases. The 
mode of onset of the two types varies. With 



178 Pneumonia 

lobar pneumonia the onset is sudden there 
may be a chill or a convulsion. Sometimes 
vomiting ushers in an attack. The fever 
rises rapidly to 103 or 105 F. The face 
is flushed and wears an anxious expression; 
the breathing is rapid, the respirations being 
from 40 to 60 a minute, the expiration being 
accompanied by a peculiar, partially sup- 
pressed sigh. The child is very restless, 
often delirious, or there may be stupor, with 
symptoms pointing to a complicating men- 
ingitis. All the symptoms disappear w r ith 
the advent of the crisis, when the fever sud- 
denly abates and fails to rise again. The 
crisis may be expected any time between 
the third and eleventh day of the recovery 
cases. In the majority of my cases it has 
occurred from the fifth to the seventh day, 
in a few not until the ninth day, and in two 
it did not occur until the eleventh day, and 
in one on the fourteenth day. 

The prognosis of lobar pneumonia in 
children is good. A very small percentage 
fail to recover. A patient of mine, a three - 
year-old boy, passed through two distinct 
attacks in a single winter, the second after 
an interval of ten weeks. 



Pneumonia 179 

In catarrhal or broncho -pneumonia the 
story is different. There may be a pneu- 
monia at the commencement of the illness, 
but according to my observation, which 
covers several hundred cases, the majority 
begin with symptoms of a common cold or 
bronchitis, the lungs becoming involved 
gradually. In other words, the onset is 
gradual, not sudden, whether it occurs inde- 
pendently or as a complication of some other 
disease. There are cough, often distressing, 
moderate fever, rapid breathing, loss of 
appetite, and, later, emaciation. Broncho- 
pneumonia in children is an affection of 
extreme gravity. There is no well-defined 
crisis as in lobar pneumonia. The disease 
may last a week or twx> weeks, or it may 
continue for months. In one of my cases, — 
a child eighteen months of age, — the disease 
continued three months before the low fever 
abated and the lungs were clear. The re- 
covery cases often require from three to four 
weeks before the lungs may be considered 
normal. 

The sick-room of a patient ill with pneu- 
monia should be large, with one window^ 
open at least four inches from the top on the 



180 The Contagious Diseases 

coldest days. The temperature of the room 
should not be below 55 F. or above 65 F. 
The child should be put on a reduced diet 
of animal broths, thin gruels, and diluted 
milk. 

Prevention resolves itself into proper care 
of the child, proper clothing, avoidance of 
unnecessary exposure, and an appreciation 
of the fact that with a child it is almost as 
necessary to call a physician for a common 
cold or bronchitis as it is for scarlet fever or 
diphtheria. 

THE CONTAGIOUS DISEASES 

A contagious disease is one due to a spe- 
cific poison which under favoring conditions 
possesses the power of reproducing itself in 
the person of another. The poison of the 
disease, the contagiiim, may be transmitted 
either directly by contact with an individual 
suffering from the disease, or indirectly by 
means of some person or object, such as the 
clothing or hands of the attendants, which 
have been in contact with the one infected. 
According to my observation, personal con- 
tact with the infected is required in a large 



The Contagious Diseases 181 

proportion of cases. Measles and whooping- 
cough are unquestionably the most con- 
tagious diseases of this type, requiring for 
their transmission only a very slight ex- 
posure. German measles and chicken-pox 
are next in order of communicability, while 
scarlet fever is less contagious than any of 
those mentioned — a close contact and a 
fairly long exposure being usually required. 
Clothing may be infected by the contagium 
of scarlet fever and diphtheria, the poison 
remaining inactive for a long time. 

A little girl, four years of age, who lived 
in one of the Hudson Valley villages, con- 
tracted scarlet fever while on a visit to a 
neighboring town ; the case was a severe one 
and the child died. A coat which she had 
worn when stricken with the disease was 
carefully laid away in a bureau drawer. 
Twelve months later the mother decided to 
give the coat to a neighbor's child. It was 
removed from the bureau, which had re- 
mained unopened, and placed on the little 
one. In five days she was attacked with 
scarlet fever. These were the only two 
cases that had occurred in the village. The 
second child had not been away from home 



1 82 Scarlet Fever 

and the jacket was the only possible means 
of infection. 

Diphtheria through personal contact alone 
is probably the least contagious of any of 
the diseases belonging in this group. Its 
virulence, however, renders every preventive 
measure imperative. 

Smallpox, thanks to compulsory vacci- 
nation, is seen so rarely that it need not be 
considered here. 

SCARLET FEVER 

Scarlet fever is one of the most important 
of the contagious diseases, and whether a 
case is mild or severe it requires the greatest 
watchfulness on the part of both physician 
and nurse, nor can their vigilance be safely 
relaxed until the patient has been apparently 
well for at least five or six weeks. The 
period of incubation varies considerably. 
In the majority of cases the first sign of 
trouble is noticed from three to five days 
after exposure. In one of my cases twelve 
days elapsed between the time of exposure 
and the initial symptom. If, however, nine 
days pass without evidence of illness, the 



Scarlet Fever 183 

child may ordinarily be considered safe, 
but the exposed should not come in contact 
with other children until at least fourteen 
days have elapsed. Infection usually takes 
place from direct contact, although the 
contagium, the nature of which is unknown, 
may be carried by means of clothing, toys, 
books, or a third person. Doctors who do 
not wear gowns while attending scarlet fever 
patients, and are careless about washing 
their hands after examining such cases, 
may themselves carry the disease. One 
attack usually protects against a second, 
although cases are on record of the occur- 
rence of two or three attacks in the same 
individual. 

The onset of scarlet fever is sudden, often 
with vomiting, occasionally with a convul- 
sion, always with fever and sore throat. 
The fever is usually high, 103 to 105 F., 
though it may be low, — 101 to 102 F. 
When the latter is the case the course of 
the disease will probably be mild. Whether 
the fever is high or low, the deeply red, con- 
gested throat is usually present. From 
twenty-four to thirty-six hours after the 
initial symptom the rash makes its appear- 



1 84 Scarlet Fever 

ance. In many mild cases it will be the 
first symptom noticed. The character of 
the rash, its intensity, and the height of the 
fever indicate fairly well the severity of the 
attack. The chest and abdomen are usually 
the site of the first appearance of the rash. 
It is composed of minute red dots so closely 
set together as to give the skin a deep scarlet 
color. The extent of the rash varies greatly; 
in some cases it covers the entire body and 
lasts from six to seven days. In others, it 
is much less distinct, covering only limited 
areas, and may last for only a few hours. 
In one of my cases it was visible for only six 
hours after it was first noticed; while in all 
other respects the case was one of typical 
scarlet fever. Ordinarily the rash begins 
to fade about the fourth or fifth day and is 
followed by the desquamation period. This 
is also variable in extent ; there may be but 
a light peeling of the palms of the hands, 
and of the finger-tips about the nails, or it 
may be most profuse, the epidermis peeling 
off in large flakes from the entire surface of 
the body. From two to three weeks are 
required to complete this process. 

Complications are a common occurrence 



German Measles 185 

in scarlet fever, and it is the complications 
which are usually the cause of death in the 
fatal cases. The kidneys, heart, lungs, and 
ears are particularly liable to serious in- 
volvement. 

An error frequently made is to allow the 
child convalescent from scarlet fever to be 
out of bed too early. He should never be 
allowed to run about before four, or, better 
still, five or six weeks have elapsed. The 
peeling may be hastened, the disease cur- 
tailed, and the danger of spreading lessened 
by a daily sponge bath followed by an inunc- 
tion with sweet oil or vaseline. 

GERMAN MEASLES 

German measles is a contagious disease 
of a very mild type, ordinarily the rash being 
the first sign of illness. This may have been 
preceded, however, by a slight chilliness and 
soreness of the muscles. The eruption is of 
a reddish-brown color and appears more 
extensively on the face and chest than on 
other parts of the body. The spots vary 
in size from a pin-head to a flaxseed. In 
well-developed cases the rash may cover 



1 86 Mumps 

the entire surface of the body. The tem- 
perature is usually low and lasts but a day 
or two. I have never seen it above 102 F. 
There is little or no inflammation of the 
eyes, nose, or throat, in marked contradis- 
tinction to measles. There is no cough and 
the child suffers very little inconvenience. 
The glands behind the ear and at the sides 
of the neck are almost always enlarged and 
sensitive, — this with the fever and the rash 
comprising the chief symptoms of the disease. 
The duration of the rash varies from one to 
three days. Usually at the end of forty- 
eight hours the skin will be found clear. 

My treatment is: two or three days in bed 
and a light diet. 

MUMPS 

Mumps is an inflammation of one or both 
parotid glands. One attack usually pro- 
tects against another. The disease is usu- 
ally acquired by contact with the infected. 
It is extremely doubtful that it can be car- 
ried by a third party. The period of time 
required for the development of the disease 
after exposure varies considerably ; but from 



Mumps 187 

two to three weeks may be considered the 
period of incubation. 

The first symptoms are similar to those 
of the other contagious diseases. There 
are loss of appetite, headache, languor, and 
slight fever. In addition to these general 
symptoms, the child complains of pain upon 
swallowing, or upon moving the jaw\ Vine- 
gar or any acid substance taken into the 
mouth causes considerable pain or discomfort 
behind the jaws and under the ears. In a 
few hours there will be noticed a swelling 
of the parotid gland in front of and under 
the ear. Both sides rarely begin to swell 
at the same time; the swelling of one gland 
usually precedes that of the other by a 
couple of days. It increases gradually for 
two or three days until it reaches its height, 
when it begins to subside slowly, reaching 
the normal in eight or ten da} r s from its 
beginning. The temperature during the at- 
tack ranges from ioo° to 103 F. 

The complications of mumps in children 
are few, and the disease cannot be regarded 
as dangerous. Acute Blight's disease fol- 
lowed an attack of mumps in one of my 
patients. Swelling of the testicles is a 



1 88 Whooping-Cough 

comparatively rare occurrence. Ear disease 
is an infrequent but possible complication. 
Multiple abscesses may develop in the parotid 
gland, but this is also a very rare occurrence. 
Other acute glandular swellings at the angle 
of the jaw are often mistaken for mumps; 
in mumps, however, the swelling is always 
in front of, under, and behind the ear. A 
simple glandular enlargement may be located 
at any point under or behind the jaw. 

A child with mumps should be kept in bed 
until the swelling has subsided, and given 
plain, easily digested food. The mouth 
should be rinsed after each meal with a 
saturated solution of boracic acid. For the 
pain and discomfort caused by the swelling, 
hot applications answer best. Flannel wrung 
out of very hot water and bound upon the 
parts always furnishes some relief. The 
flannel should be kept hot by repeatedly 
dipping it into hot water. The heat will 
be retained better if the flannel is covered 
with oiled-silk. 

WHOOPING-COUGH 

In whooping-cough we have one of the most 



Whooping-Cough 189 

dangerous diseases of childhood, dangerous 
in the extreme for the very young, the deli- 
cate, and the rachitic. In itself it is seldom 
directly fatal, but the frequent complica- 
tions of catarrhal pneumonia in winter 
and intestinal diseases in summer make it 
indirectly responsible for the loss of many 
lives. 

The period of incubation ranges from 
seven to fourteen days. At the commence- 
ment of the disease the cough is not severe 
and often cannot be distinguished from that 
of bronchitis or a common cold. The cough, 
however, does not respond to treatment 
for coughs and colds; it increases in severity, 
becoming paroxysmal in character and worse 
at night. During the paroxysms the eyes 
water, the face becomes red and congested, 
the seizure often ending in vomiting. The 
characteristic whoop usually develops after 
ten days or two weeks. In the mild cases 
there may be but two or three paroxysms 
daily; in the severe cases there are usually 
from twenty to thirty in twenty-four hours. 
I have seen a few cases in which the disease 
was so mild that the whoop never appeared, 
while others whooped but once during an 



190 Whooping-Cough 

entire attack. The disease varies not only 
in its severity, but in its duration as well. 
Occasionally cases are seen which run the 
entire course in four weeks; unfortunately, 
they are rare. As a rule, from eight to ten 
weeks elapse before the child may be con- 
sidered well. 

As long as the child, continues to whoop, 
or the cough is distinctly paroxysmal, it is 
not safe for him to come in contact with 
the unprotected. The active stage, during 
which the paroxysms are frequent and 
severe, rarely lasts longer than two or three 
weeks. Sometimes after a period of three 
or four months without whooping, the child 
takes cold, develops a cough paroxysmal in 
character, and the whoop returns; but this 
does not mean that there is a return of the 
whooping-cough, and such children need 
not be quarantined. 

Whooping-cough cannot be cured ; it must 
run its course. The author's observations, 
which cover the management of over one 
thousand cases, prove that every case may 
be ameliorated and its course perhaps short- 
ened. The home treatment demands an 
abundance of fresh air. The child should 



Diphtheria 191 

spend the greater part of every pleasant day 
out of doors and sleep with the window open 
an inch or two from the top, regardless of 
the weather. 



DIPHTHERIA 

Diphtheria is a disease due to a germ 
which is known as the Klebs-Loeffler bacillus. 
It lodges upon the mucous membrane of the 
throat or nose, and there starts up a process 
known as diphtheria. The disease is usually 
of slow and insidious onset, requiring two or 
three days for its complete development. 
The period of incubation varies greatly; a 
child may develop diphtheria within twenty- 
four hours after exposure, or it may be 
delayed a month or six weeks. In children 
who have been exposed, there should be a 
microscopical examination of the secretion 
from the throat, which may settle the ques- 
tion as to the child's liability to contract the 
disease. 

The first symptoms are fever and rest- 
lessness, loss of appetite, and disinclination 
to play. The child may complain of pain 
upon swallowing, and in many cases, very 



192 Diphtheria 

early in the attack, swelling may be noticed 
at the angle of the jaw. Inspection of the 
throat shows the characteristic patches of 
the membrane. In some cases these patches 
resemble a thin layer of putty spread over 
the parts. Others present the appearance 
of a very light-yellow paint splashed upon 
the tonsils and adjacent parts. The mem- 
brane may be located in the nose, throat, 
larynx, eye, — in fact, any mucous surface 
may become infected; fresh wounds may 
also become infected. The usual sites, how- 
ever, are the nose, throat, and larynx. The 
disease may be transmitted by direct con- 
tact, by means of contaminated clothing, toys, 
pictures, books, or the germs may be carried 
on the hands or clothing of an attendant. 
One attack does not protect against 
another. There is evidence that a certain 
degree of immunity is established, but it 
probably is not effective for more than a 
few months. Diphtheria does not run a 
definite course, like the other infectious 
diseases. We cannot say that certain defi- 
nite signs will be present on certain days. 
It is the most uncertain and treacherous 
disease with which w T e have to deal. 



Diphtheria 193 

The only treatment of value other than 
supportive measures is the use of antitoxin, 
which must be given early in the disease- — 
as soon as a diagnosis of diphtheria is made. 
In fact, I believe it is advisable to give it 
in all cases where there is any uncertainty 
as to whether the case is tonsillitis or diph- 
theria. Much valuable time may be lost 
by delay. The antitoxin should be repeated 
in from twelve to twenty-four hours if im- 
provement does not follow. I have been 
obliged in four cases to give three injections 
of 5000 units each. In one severe case, in- 
jections of 40,000 units were required. In the 
majority of my cases two injections of 5000 
units each were required. 1 No harm results 
from the use of antitoxin. I have employed 
it in a great many cases and have lost but 
two. One child I did not see until the fourth 
day of its illness, which was too late for the 
antitoxin to be of any service. The general 
mortality of diphtheria has been markedly 
reduced through its use. During conva- 
lescence, the child must not be allowed to 

1 In the very severe cases in which there is early in- 
volvement of the nose or larynx, from 8000-10,000 
units should be given at the first injection. 

13 



194 Chicken-Pox 

mingle with other children until a bacteri- 
ological examination of the throat shows it 
to be free from diphtheritic germs. 

The instructions for the preparation of 
the sick-room, for disinfection and quaran- 
tine, will be found on pages 198-201. 

CHICKEN-POX 

Chicken-pox is one of the milder con- 
tagious diseases. Among several hundred 
cases I have seen but two that were severe 
enough to endanger life. 

The period of incubation is quite long, — 
from fourteen to tw r enty-one days. There 
is slight fever at the onset, rarely high 
enough, however, to be noticed by the 
mother or nurse. More frequently the first 
sign of the disease is the characteristic 
eruption which may appear on any portion 
of the body, the scalp sometimes being 
particularly involved. The rash consists 
of very small blisters which from a distance 
give to the skin the appearance of having 
been sprinkled with water. The fluid soon 
disappears, leaving a dark-colored crust. 
When the crusts fall, a small scar is often 



Measles 195 

left, which may remain for several months. 
In an ordinary case the skin will not be clear 
before the end of the third or fourth week. 

The child should be kept indoors during 
the attack, and given a reduced diet. The 
itching is often relieved by sponging with 
a weak solution of alcohol in water, — four 
ounces to a pint, — followed by a gentle 
application of vaseline. 

I never advise quarantine against chicken- 
pox except to avoid needless exposure of very 
young or delicate children in the family. 
The patient should not return to school or 
be allowed to mingle with other children — 
in short,, is not to be considered-^well until 
the skin is clear. 

MEASLES 

The incubation period of measles- — the 
time required between the exposure and the 
development of the first symptom — varies 
between nine and twelve days. One attack 
usually protects against a second. This, 
however, is not invariably the case. I have 
a patient, a young girl, eighteen years old, 
who contracts measles every time she is 



196 Measles 

exposed. She recently passed through her 
fourth t-:tack, which was most severe. 

The onset of the disease closely resembles 
that of a common cold. The symptoms are 
slight fever, ioo° to 102 F., redness of the 
eyes and intolerance of light, a watery dis- 
charge from the nose, a dry, hard cough, 
pain on swallowing, and loss of appetite. 
The peculiar swollen, congested condition of 
the eyes and face often makes a diagnosis 
possible before the appearance of the rash. 
This usually first appears, from the second 
to the fourth day of the illness, upon the face 
and chest. At first there are small, irregu- 
larly shaped spots said to resemble fleabites. 
The spots coalesce, the rash extends, and 
in one or two days the greater portion of the 
skin is involved. The rash remains at its 
height for two or three days, when it begins 
to fade, and in two or three days more the 
skin becomes clear. With the subsidence 
of the rash, desquamation or peeling of the 
skin begins. This consists in the shedding 
of fine, thin scales. The fever and prostra- 
tion keep pace fairly well with the rash. 
The fever, which may range between 102 
and 105 F., reaches its highest point with 



Measles 197 

the complete development of the rash. With 
the fading of the rash the fever also mod- 
erates. The cough in measles is hard and 
dry in character and is often quite severe. 
It must be remembered that the congestion 
of the respiratory mucous membrane which 
causes the cough is a part of the disease. 
The cough may be relieved, but it will not 
subside until the disease has run its course. 
There is always considerable involvement 
of the eyes, the lids being red and swollen, 
with a free secretion of watery mucus. In 
many families but little attention is paid 
to measles — it is regarded with more or less 
indifference. While, in most instances, the 
disease may not be particularly dangerous, 
we must remember that it is sometimes quite 
virulent, and domestic treatment should 
never be relied upon. There is always more 
or less bronchitis, which in young and deli- 
cate infants constitutes a severe complica- 
tion, leading, as it often does, to catarrhal 
pneumonia. 

The eyes should be washed daily with a 
saturated solution of boracic acid. Their 
sensitive condition requires also a darkened 
room, and failure to appreciate this fact 



198 The Sick-Room 

has often resulted in their permanent injury. 
A darkened room, however, does not mean 
a room devoid of ventilation; fresh air for a 
patient with a contagious disease is almost 
as important as nourishment. The diet 
must be simple; only fluid diet should be 
given to " runabouts,' ' while for infants the 
usual milk mixture should be diluted with 
boiled water from one-third to one-half. 
The child should have a lukewarm sponge- 
bath every day, followed by an inunction 
of vaseline, which not only relieves the 
itching, but renders the patient much more 
comfortable. 

Children convalescent from measles should 
not be allowed to go to school or mingle with 
the unprotected until two weeks after the 
completion of desquamation. 

SICK-ROOM FOR CONTAGIOUS DISEASES 

QUARANTINE 

A child ill with a contagious disease should 
always be isolated, whether there are un- 
protected children in the family or not. 
Quarantine can be carried out only when 
the child is placed in a room alone with the 



The Sick-Room 199 

nurse or mother, and neither allowed to 
leave the room or in any way to come in 
contact with other members of the family. 
If possible the room should be on the top 
floor of the house. The furniture should be 
of the simplest, — no fancy curtains and no 
upholstery. A perfectly bare floor is best. 
If two nurses are required, two isolating 
rooms will be necessary, one to be used as a 
sleeping-room. The meals should be carried 
on a tray and placed upon a chair outside 
the closed door of the isolating room. The 
dishes containing the food are to be removed 
by the person isolated. After use, before 
returning the dishes to the chair outside the 
door, they should be placed for five minutes 
in boiling water. Only wash goods should 
be worn by the attendants, and their cloth- 
ing, with bed linen when changed, should 
be placed in boiling water 1 — one ounce of 
carbolic acid to two gallons of water — before 
it is sent to the laundry. 

When other members of the family are 
allowed to go at will into and out of the 
isolating room, the value of the quarantine 
is practically lost. If the illness is of a 
serious nature, such as scarlet fever or 



200 The Sick-Room 

diphtheria, the other children of the family 
should be sent to other quarters ; particularly 
should this be done if the family occupy an 
apartment. 

DISINFECTANT DRUGS 

The erroneous views possessed by many 
concerning disinfection often result in much 
harm. Too many are satisfied by the use 
of disinfectant solutions and drugs at the 
expense of cleanliness. Any agent that will 
destroy germs is a disinfectant. Disinfec- 
tion really means cleanliness. Disinfectants 
can never supplant hot water, common 
yellow soap, and a nail-brush. Dipping the 
hands into a solution of carbolic acid or 
bichloride of mercury will not make them 
clean, much less sterile. Sprinkling either 
of these substances upon the floor will not 
clean the floor or be of one particle of service. 
Scrubbing the floor of the sick-room once a 
day, using hot water, sapolio, and a stiff 
brush, will do more to prevent the circu- 
lation of the germ-laden dust than any 
disinfectant which can be used. I recently 
saw a young mother change the baby's 



y 



Disinfection 201 

napkin, immediately after which, with hands 
untouched by soap or water, she very care- 
fully washed out the baby's mouth with the 
boracic acid solution! The young mother 
was anxious to do her full duty by the child, 
but had never learned the rudiments of 
disinfection. 

Disinfectant solutions and drugs are of 
much service when used after a thorough 
scrubbing with hot water, soap, and brush, — 
never before. 

DISINFECTION AFTER CONTAGIOUS 
DISEASES— FUMIGATION 

Before being allowed to resume his place 
in the family, the child who has recovered 
from a contagious disease should be given 
a tub-bath, with a vigorous scrubbing with 
soap and warm water. The hair should be 
washed with a 1 to 2000 solution of bichlo- 
ride of mercury, and the child dressed in 
fresh clothing outside the sick-room. 

The soiled clothing and the bedding which 
can be washed should be put into a solution 
of one ounce of carbolic acid to two gallons 
of water. The vessel should be covered and 



202 Fumigation 

removed to the laundry and the clothing 
boiled thirty minutes. The bedding and 
such articles as cannot be washed should be 
spread over the furniture in readiness for 
fumigation. 

The windows and doors must be closed 
and sealed, when the room can be fumigated 
with sulphur or formalin. If sulphur is 
used, three pounds of roll sulphur are re- 
quired by the New York Health Department 
for every thousand cubic feet of air space. 
The sulphur is placed in an iron vessel which, 
as a precaution against fire, should stand 
on a large piece of tin or zinc. Alcohol is 
poured over the sulphur and ignited, after 
which the room should not be opened for 
twenty-four hours. If the air in the room 
can be charged with a moderate amount 
of vapor from an open vessel on a stove or 
radiator, the sulphur disinfection will be 
more complete. Formalin acts as a much 
better disinfectant and is far less objec- 
tionable than sulphur. The formalin appa- 
ratus with directions for its use can be rented 
at a moderate price from most New York 
druggists. 

After the fumigation, the carpet or rugs, 



The Delicate Child 203 

mattresses and pillows, are taken charge 
of by the health authorities in the larger 
cities, steamed, and returned in two or three 
days free of expense to the owner. Other- 
wise such articles should be sent to the 
cleaner and the mattresses and pillows 
re-covered. The floor of the room and the 
woodwork should be scrubbed with hot 
water, brush, and soap. When dry they 
should be washed with a 1 to 2000 solution 
of bichloride of mercury. The furniture 
should also be washed with the bichloride 
solution. If the walls are papered, they 
should be wiped with cloths moistened with 
this solution; but it is better to have the 
room re-papered. If the walls are painted, 
they should be washed with the solution. 
If the walls can be newly papered, painted, 
or kalsomined, much greater security will 
be enjoyed by the future occupant. 

THE DELICATE CHILD 

In work among children one frequently 
meets with those who, while they cannot 
be said to be suffering from any disease or 
pathologic condition, yet are inferior in 



204 The Delicate Child 

physical development, lack endurance, and 
possess poor resisting powers. They are 
often under height, always under weight, 
and, in short, have so many character- 
istics in common that they constitute a 
class by themselves, and as such warrant 
our attention. 

Normal development. — The average child, 
at the various periods of early life, conforms 
with a certain degree of regularity to the 
mental and physical development which 
by long association we have come to regard 
as normal. Thus a standard may be said 
to have been established, and it is up to 
this standard that we expect the growing 
child to measure. This is what we look 
upon as the average of physical and mental 
development. A few children exceed these 
requirements: they are stronger and larger 
at the sixth month than the average child at 
the ninth month. Again, older children 
at the fourth or fifth year are in every way 
equal to their normal playmates a year or 
two older. 

Abnormal development. — On the other 
hand, there are children who are born with 
a reduced vitality, or who, through faulty 



The Delicate Child 205 

management, usually in relation to feeding, 
acquire a reduced vitality. Semi-invalid 
adults almost invariably beget semi-invalid 
children. If the parents are of average 
health and of good habits, and the debilitated 
condition of the child is due to faulty man- 
agement and nutritional errors, the result 
of proper dietetic and hygienic management 
is usually prompt and satisfactory. With 
the persistently delicate, the offspring of 
physically enfeebled parents, the results are 
less satisfactory, but improvement is always 
possible. 

Management. — By proper regulation of 
the habits of a delicate child, as regards all 
the details of his daily life, a far better adult 
is produced than if no such effort had been 
made. In other words, a diet and general 
regime of life best adapted to the individual 
in question will invariably improve the 
physical condition of that individual. This 
applies to the strong as well as to the deli- 
cate, to the growth and development of the 
young of the lower animals as well as to the 
offspring of man. It is the poorly developed, 
delicate child that we are particularly to 
consider — the undersized, frail, small-boned, 



206 The Delicate Child 

under- weight child, whose appetite is per- 
sistently poor or capricious, who sleeps 
poorly, tires easily, is usually constipated, 
who is subject to catarrhal conditions of 
the respiratory tract, and whose powers 
of resistance generally are diminished. In 
not every delicate child will all these symp- 
toms be found. Under- weight and one or 
more of the other conditions referred to will 
usually be present. 

On assuming the management of one of 
these children it is absolutely necessary to 
make a thorough examination, followed in 
some instances by a few weeks' observation, 
in order to become acquainted with the case 
in its individual aspects, to learn idiosyn- 
crasies, and to eliminate the factor of actual 
disease as a causative agent. When w T e 
demonstrate to our satisfaction that the 
child is free from such diseases as tubercu- 
losis, kidney disease, and malaria; w T hen we 
have eliminated by properly directed treat- 
ment all causes, such as adenoids, phimosis, 
adherent clitoris, vaginitis, or parasitic and 
irritant skin lesions, which may have had 
a deterrent influence upon growth ; and when 
we have satisfied ourselves as to the actual 



The Delicate Child 207 

condition of our patient, we are in a position 
to lay down definite rules of management. 

Every child has a distinct function to 
perform. As soon as he is born he is con- 
fronted with a serious problem — the prob- 
lem of growth, physical and mental. Inas- 
much as this growth and development de- 
pend, above all things, upon a properly 
adapted food supply, it must be our first 
step to provide such nutriment as will be 
most conducive to it. As growth takes place 
in all parts of the bod}' through cellular 
activity, the nutritive elements which sup- 
port cell proliferation must be important 
constituents of the diet, and among these 
the proteids are of prime importance ; hence ■ 
in the management of these children a point 
to be remembered in the adaptation of the 
food is the necessity of feeding as rich a 
proteid as the child can assimilate. The 
younger the child, the greater the necessity 
for growth. 

Regular weighings necessary. — An infant 
should be weighed at regular intervals, and 
if under one year of age, should not be con- 
sidered as doing even passably well if not 
gaining at least four ounces weekly. When 



2o8 The Delicate Child 

a baby remains stationary in weight its 
development is invariably abnormal. When 
stationary or when only a slight gain of 
one or two ounces weekly is made, we will 
always find after a few weeks that there is 
malnutrition, in spite of the apparent gain, 
as will be evidenced by the symptoms of 
beginning rickets — anaemia, the character- 
istic bone changes, flabby muscles, and a 
tendency to disease of the mucous mem- 
branes. Delicate infants should be weighed 
daily at first; then, as improvement takes 
place, at intervals of two or more days, but 
never less frequently than once a week, if 
under one year of age, no matter how vig- 
orous they may become. The weighing 
keeps us directly in touch with the child's 
condition, but since the increase may be in 
fat alone, an occasional examination of the 
child stripped is necessary to tell us whether 
there is substantial growth in bone and 
muscle. 

Feeding delicate infants. — When it is de- 
monstrated that a child will not thrive on 
the breast of the mother, another breast 
should be substituted, or an adapted high- 
proteid cow's milk should form the diet in 



The Delicate Child 209 

part or in whole. If the child is bottle-fed 
and it is demonstrated that proper growth 
and development are impossible on cow's 
milk, on account of proteid incapacity, then 
a wet-nurse should be secured. 

When, after the first year, more liberal 
feeding is allowed, the necessity for a high 
proteid in the food selected is as urgent as 
before. This applies to those children who 
are brought to us showing evidences of late 
malnutrition, as well as to those whom 
we have had under our care from early 
infancy. 

An important element in the diet up to the 
third year, is milk. A child from the first 
to the third year ought to receive one quart 
of milk daily. Unfortunately, many debili- 
tated children have a very poor capacity 
for fat assimilation. When given full milk 
in as small an amount as one pint daily, 
they often develop foul breath, coated 
tongue, and loss of appetite, or they suffer 
from frequent attacks of acute indigestion. 
The milk is necessary, not because of the 
fat, which can easily be dispensed with, but 
because of the high percentage of proteid 
which it contains — from three to four per 



210 The Delicate Child 

cent. When this fat incapacity exists, the 
milk is said to " disagree/' but skimmed 
milk will be taken without inconvenience. 
Enough sugar may be added to bring the 
percentage up to seven, in order that it 
may replace the fat, for fuel. Skimmed 
milk with sugar added furnishes a food of 
no mean order. Too much milk, however, 
must not be given. When large quantities, 
more than one quart daily, are taken, the 
desire for more substantial nourishment, 
such as eggs, meat, and cereals, is removed. 

At the completion of the first year, keep- 
ing in mind a high proteid, begin with 
scraped beef, at first one teaspoonful once 
a day, in addition to the cereal and milk. 
If this is well borne, and it usually is, a tea- 
spoonful may be given twice a day, and 
later three times a day. It may be given 
immediately before the bottle-feeding. 
Eggs should be brought into use from the 
twelfth to the fifteenth month. At first 
one-half an egg, boiled two minutes, is given 
mixed with bread-crumbs. If w T ell borne, 
a whole egg may be allowed. The cereals 
used should be those most rich in vegetable 
protein, such as oatmeal, containing 16 per 



The Delicate Child 211 

cent, of proteid, dried peas, 20 per cent, of 
proteid, and dried beans, containing 24 per 
cent, of proteid. The peas, beans, and lentils 
should be given in the form of a puree. 

Diet after the first year, — If the child during 
the second year has an indifferent appetite, 
reduce the quantity of milk; never allow 
more than one pint of milk daily for the first 
week or two. Many delicate children who 
apply for treatment after the first year of 
age have been subjected to as grave errors 
in diet as are seen among the bottle-fed. 
Starch foods and milk oftentimes furnish 
the only means of nutrition up to the fourth 
or fifth year, the starch used being generally 
in the form of bread, crackers, and indif- 
ferently cooked cereals. In one case four 
quarts of milk were taken daily by a boy 
of seven years. 

It will be seen that it is our aim in this 
class of children — the delicate, undersized, 
slow-growing class — to give as liberal a 
nitrogenous nourishment as is compatible 
with the digestive capacity of the patient. 
But if the child has had rheumatism, or if 
there is a tendency to lithiasis, the use of 
a large amount of meat is contra-indicated. 



212 The Delicate Child 

It is in such children that the high-proteid 
cereals are particularly valuable. In a gen- 
eral way, from early life the diet of the 
delicate child should consist of milk, suit- 
ably adapted, with highly nitrogenous cereal 
added, when permissible. Many delicate 
children of the " runabout' ' age who cannot 
digest milk containing 4 per cent, of fat will 
easily digest butter fat when spread on bread 
or potatoes. In this way I often use it 
to supply fuel to act as a proteid-sparer. 
Oatmeal-water or oatmeal-jelly, mixed with 
the milk, should be order at the seventh 
month. When age allows, the addition 
of raw or rare meat, poultry, eggs, and 
purees of dried peas, beans, and lentils 
should be given. Boxed "ready to serve" 
cereals are never given; raw cereals are used, 
which are cooked three hours. While a 
high-proteid diet is desirable, other things 
are necessary. Green vegetables, animal 
fats, the ordinary cereals, cooked and raw 
fruits, are required to furnish the necessary 
acids and salts, as well as the necessary 
variety. In short, the ideal diet for a deli- 
cate child is that combination of food which, 
while imposing the least burden upon the 



The Delicate Child 213 

digestive organs, supplies the body with 
material exactly sufficient for its needs, and 
such a food must be rich in nitrogen. (See 
dietary, page 73.) 

Baths. — On account of the fear that a 
delicate child may take cold, the bath is 
often omitted. Every child, both the well 
and the delicate, after the second week 
should be tubbed daily. The delicate par- 
ticularly require it. The salt bath (page 
117) is usually advised. The best time for 
giving the bath is at bedtime, and in order 
to avoid all chance of exposure the tempera- 
ture of the room should be elevated to 8o° F. 
The temperature of the water may vary. 
It should never be above 95 F. except for 
very delicate young children in whom there 
is a tendency to a subnormal temperature. 
Even in these cases the temperature of the 
bath should never be higher than the tem- 
perature of the body. In the frail and in 
the very young the bath should not be con- 
tinued over five minutes. In older children, 
those of eighteen months or over, if the phys- 
ical conditions allow, a distinct advantage 
will be gained by a reduction of the tem- 
perature of the bath while the child is in 



214 The Delicate Child 

the water. An immersion in water at 90 F. 
followed by a gradual reduction during the 
space of five or six minutes to 70 F. should, 
upon brisk rubbing, be followed by a quick 
reaction. If the reaction is not good, if the 
extremities are cold and are slow in becoming 
warm, the reduction in the temperature 
should be less or none at all. In the very 
poorly nourished, a reduction below 8o° F. 
should not be attempted. Following the 
drying process, primarily for the benefit of 
the massage, goose oil or olive oil should be 
rubbed into the skin over the entire body 
for from five to ten minutes. The bath 
and the massage inunction, besides favor- 
ably influencing nutrition, are a very effec- 
tive means of inducing sleep. 

Fresh air. — Delicate children are usually 
deprived of a proper amount of fresh air, 
for the same reason that they are insuf- 
ficiently bathed — the fear of making them 
ill. All children need an abundance of 
fresh air, both in illness and in health. The 
robust and the delicate require it, and to 
the delicate it is much more essential than 
to the robust. As many hours daily as 
practicable should be spent out of doors. 



The Delicate Child 215 

The time thus spent depends upon the 
season of the year and the residence of the 
child, whether in the city or the country. 
In the city, during the colder months with 
pleasant weather, the child should spend 
at least five hours daily in the open air, 
dividing the day into two outing periods — 
from 9 to 11.30 in the morning and from 2 
to 4.30 in the afternoon. On very cold 
days, 20 P. or below, on stormy days, and 
on days with very high winds, the child is 
given his airing indoors. He is dressed as 
for out of doors, placed in his carriage, and 
left in a room, the windows on one side of 
the room being open. Not infrequently 
during February and March delicate chil- 
dren will be prevented from going out of 
doors for several consecutive days. If some 
means for a daily systematic indoor airing 
is not provided, these children will often 
go backward, no matter how excellent the 
other management. The first symptoms 
are loss of appetite and the ability to assimi- 
late the food. In my private work among 
marasmus cases, the child is placed in the 
baby-carriage or in a basket and allowed 
to rest before an open window for ten or 



216 The Delicate Child 

twelve hours of every twenty-four, with a 
hot-water bottle at his feet. Here he is 
fed, being removed only temporarily to 
warmer quarters for a change of napkins. 
I have several roof gardens in operation. 
A boy patient nine months of age has been 
in the street only once in four months, then 
only in going to church to be baptized. 

Sleep. — The delicate child requires no 
more sleep than does the strong, and the 
rules governing this matter at the various 
periods of life are the same both for the 
strong and for the weak. (See Sleep, page 
299.) The sleeping-room of the delicate 
child should always communicate with the 
open air by a window, either directly or 
through an adjoining room. A satisfactory 
method of ventilation is by the window- 
board (page 13). The child should occupy 
the room alone, if possible, sharing it neither 
with an adult nor another child. This ap- 
plies to all ages, but is particularly neces- 
sary after the second year. 

The nursery.' — The temperature of the 
nursery, day or night, should never be above 
70 P., during the colder months, and in 
the case of the very young, or in those who 



The Delicate Child 217 

are difficult to keep covered, it should not 
go below 65 P. at night. 

Delicate children of the "runabout" age 
are very susceptible to colds. In the man- 
agement of such children it is necessary to 
use every precaution against exposure. The 
most frequent way of exposing a child to 
cold is by allowing him to sit on the floor. 
To keep the child of from ten months to 
three years of age off the floor during the 
winter months, and thereby to eliminate 
this means of exposure, is a very difficult 
matter. In fact with active children, learn- 
ing to walk, or who have just learned to 
walk, it is practically impossible under the 
usual conditions. During the colder months 
there is always a current of cold air near the 
floor, and allowing the child to creep in win- 
ter, even if the floor is protected by rugs 
and carpets, is one of the surest ways of 
permitting him to take cold. If he is allowed 
to walk on the floor he is soon very sure to 
sit down. If he is not allowed to creep and 
walk about at will, he will not get the proper 
exercise and will show faulty development. 
For such cases I have found the exercise 
pen of immense service (see Fig. g.). After 



218 The Delicate Child 

being dressed, washed, and fed, the child is 
placed in the pen, on a rug if desired. Toys 
are given him and the door is closed. He 
can now roam about at will, stand up, sit 
down, creep, or walk without the slightest 
danger from drafts. 

I;:f!uence of climate. —Much has been writ- 
ten regarding the influence of climate in 
the type of case we are considering. Accord- 
ing to my observation, this matter does not 
deserve the attention it has received. The 
city child in a well-to-do family is, as a rule, 
better off for eight months of the year in his 
own home with its usual conveniences. The 
benefits attributed to change in climate are 
usually the result of a change not of climate 
but to more fresh air, which is afforded by 
the larger rooms of the hotel, with its loosely 
constructed doors and windows; and since 
the parent is desirous that the child shall 
receive the full benefit of the change, he is 
kept in the open air for a much longer time 
than when at home. The air at such a 
place is more expensive, and consequently 
more appreciated than the air at home. 
With sufficient heat and proper ventilation, 
we mav make our own climate. It is not 



The Delicate Child 219 

to be denied, however, that a change of 
residence for a few weeks from Xew York 
to Lakewood or Atlantic City during March 
and April is sometimes of advantage. 

From the first of Tune to the first of Octo- 
ber the delicate child should not remain in 
New York City. The humidity and the 
heat which may prevail for f rotracted periods 
during this time render it unsafe, particu- 
larly during July and August. The sea- 
shore for the entire summer is not to be 
advised. The children whom I have sen: 
inland to the country and to the mountains 
have, as a rule, returned in the autumn in 
a much better physic o than those 

who spent the summer by the sea. 

Clothing. — Thin, poorly nourished children 
require more clothing than do those phys- 
ically normal. A fairly good index as to 
whether a child is sufficiently clad is the 
condition of his lower extremities. The 
forearm and hand cannot be relied upon. 
The legs and feet of every child should always 
be warm to the touch. 

As to the nature of the clothing. — A mixture 
of silk and wool next to the skin is most 
desirable. As a second choice a mixture 



220 The Delicate Child 

of wool and cotton is used. The linen mesh, 
often useful in the vigorous " runabout' ' is 
not to be advised in the delicate. 

Exercise. — Moderate exercise is to be en- 
couraged. But it should never be allowed 
to the point of fatigue. In large cities all 
delicate " runabouts" from three to five 
years of age should be allowed to walk not 
more than six blocks in going to the play- 
grounds. If the distance is greater, the 
child should ride part of the way, play or 
walk for a time, and then be placed in the 
carriage or cart and ride home. Younger 
children, two or three years of age, should 
be wheeled both ways and taken out at the 
park for a run when the weather conditions 
permit. 

Midday nap. — Every day after the midday 
meal the child, regardless of age, whether 
two years or six, should be undressed and 
put to bed for two hours. He should be 
left alone in the room, and whether he sleeps 
or not he should remain in bed for the two 
hours. 

Entertainment. — Entertaining play is neces- 
sary, but every kind of excitement, such as 
children's parties, emotional plays at the 



The Delicate Child 221 

theatre, and rough play with older children, 
should be avoided. 

Education. — The delicate child under eight 
years of age should be taught only to the 
extent of strict obedience and good habits. 
Other than this he should be a little animal. 
There should be no teaching in the ordinary 
sense of the term, no mental stimulation, 
until the child is physically able to bear it. 
When school-work begins, which in this 
class of children should never be before the 
eighth year, the studies should be made 
easy and the school hours short. Such 
children should never be crowded. I usu- 
ally direct that they attend only the morn- 
ing session. 

The delicate child should be carefully 
watched from the time it comes into our 
hands until it reaches the normal or until 
the period of development is completed. 
While the scheme of management as out- 
lined will not always be attended with 
brilliant results, it will not be in vain. Many 
lives will be saved, and as a result of the 
increased acquired resistance, stronger men 
and women will be added to the race than 
would otherwise have been possible. 



222 Premature and Weak Infants 

PREMATURE AND COXGENITALLY 
WEAK INFANTS 

There are comparatively few infants born 
before the completion of the twenty-eighth 
week of pregnancy that survive the first 
year. Reported cases of survival of those 
born before that time are usually unreliable, 
as they seldom take the child beyond the 
third month. The prognosis is influenced 
by the factors causing the premature birth. 

In the management of the premature and 
delicate newly born there are three points to be 
considered — the air the child gets to breathe, 
the nourishment, and the maintenance of 
bodily heat. It is also to be remembered 
that we are dealing with an undeveloped 
body which is not ready for the environ- 
ment in which it is placed. The premature 
baby should be handled only when necessary, 
and then in the gentlest manner. Bathing 
is often best omitted for the first few weeks, 
oil being used for cleansing purposes. Be- 
cause of the undeveloped parenchyma of 
the lungs usually good fresh air is required. 
Because of the undeveloped heat-centres 
the body -heat of the premature infants is 



Premature and Weak Infants 225 

meekly lost and must be maintained 

artificial means. The stomach is small and 
the digestive processes are undeveloped and 

weak, so that the nourishment should te of 
die most easily assimilable character. 

The maintenance of heat is of the utmost 
importance. For this purpose incubators 
and their various modifications have been 
used from time to time. My experience 
with incubators has been unsatisfactory. 
They may by careful watching maintain 
an eve:: temperature, but ah chat I fc 
used have been defective in supplying fresh 
air to the child. My incubator babies have 
usually done badly. Removal from the 
:r v.-as necessary. If the electro- 
therm (Fig. 12) is not at hand, the padded 
crib with the child wrapped in cotton and 
surrounded by hot-water bottles is the best 
means of maintaining the temperature. A 
thermometer she via rest between the cotton 
and the bed-clothing; as a guide to the nurses 
in the use of the hot-water beetles. Ordi- 
narily this should register from S; to 05° P., 
dec ending upon the temperature of the 
child, whose rectal temperature should at 
first be taken frequently. If there is a 



224 Premature and Weak Infants 

tendency for his temperature to be greatly 
reduced — below 95° F. — more external heat 
will be necessary than if the temperature 




FIG. 12. THE ELECTROTHERM 

were 97 or 98 F. The best device among 
those which I have had an opportunity to 
observe for maintaining artificial heat is 
the electrotherm advocated and described 
by Holt, Diseases of Infancy and Childhood, 
1906. 

"These small heaters are attached to an 
electric fixture, like a drop-light. A con- 
venient size is from ten to fifteen inches. 
It is placed between two or three thicknesses 
of blankets, upon which the infant lies in 



Premature and Weak Infants 225 

its basket or crib. The degree of heat can 
be regulated according to the amount of 
electricity turned on. This mode of hand- 
ling premature infants has been given thor- 
ough trial at the Babies' Hospital and has 
been found to fulfil the indications, with 
children as small as three pounds and as 
young as seven months, quite as well as 
the incubator, while at the same time being 
free from its dangers. It has not been 
necessary to raise the general temperature 
of the room. These patients when kept 
in the wards at an ordinary temperature 
have maintained an even bodily tempera- 
ture much more uniformly than with any 
other method I have seen, the incubator 
included/ ' 

A mistake often made in the management 
of premature and delicate infants is that 
of providing too warm air for respiration, 
a glaring defect in most incubators. The 
best means of decreasing a delicate child's 
vitality and resistance and increasing his 
chances of pulmonary infection, is to supply 
him constantly with air at 8o° to 90 F. 
In a modern house the maintenance of this 
temperature usually means an absence of 
is 



226 Premature and Weak Infants 

change of air and an abundance of bacteria. 
The patients do best when the temperature 
of the air they breathe is from 70 to 72 F. 
Breast-milk for premature infants born 
under twenty -eight weeks is almost a neces- 
sity, and should always be procured when 
possible for all premature children. The 
mother, with the rarest exception, is unable 
to supply it, so that a wet-nurse should be 
secured. In selecting a wet-nurse for a 
premature baby it is advisable to take 
the wet-nurse's baby also, as the prema- 
ture infant may not be able to nurse, or 
if he nurses he will not take all the milk. 
Pumping the breasts of a wet-nurse will 
almost invariably dry them up, if her own 
baby is not with her to furnish the necessary 
stimulation of nursing. Sufficient milk may 
be removed by the breast-pump to supply 
the premature infant if he is unable to nurse, 
and the wet-nurse's baby will empty the 
breast. For premature babies who refuse 
the breast or are unable to take a nipple, 
the Breck feeder (Fig. 13) may be used as 
a means of giving nourishment, or gavage, 
forced feeding with a tube, may be brought 
into use. This I have been obliged to re- 



Premature and Weak Infants 227 



sort to in several cases. The Breck feeder 
consists of a graduated glass tube, nar- 
rowed at one end. Over this 
end is placed a small rubber 
nipple, the other end being 
closed by a flexible rubber 
cap. Drawing on the nipple 
is aided and encouraged b}^ 
pressure on the air-filled cap.- 
If the breast-milk proves too 
strong it may be diluted with 
equal parts of a 6 per cent, 
sugar solution, from one-half 
to one ounce of the mixture 
being given at first at intervals 
of from one to one and one- 
half hours. Fourteen to fif- 
teen feedings may be given 
in the twenty-four hours, the 
amount depending upon the 
child's digestive ability. If hu- 
man milk is not obtainable, 
whey made from whole milk 
may be given, or one ounce of 
gravity cream may be given with one ounce 
of milk-sugar, one ounce of lime-water, and 
fourteen ounces of water. Canned con- 



FIG. 13. THE 
BRECK FEEDER 



228 Glands 

densed milk, one part, to from 24 to 30 parts 
of water, may be used with advantage as 
a temporary feeding measure when nothing 
better is available. The food strength is 
increased, the intervals made longer, and 
the feeding larger, as the patient proves able 
to assimilate the food. 

GLANDS 

ACUTE ENLARGEMENT OF THE GLANDS OF THE 
NECK 

A mother is often alarmed by the sudden 
appearance of a hard swelling in the neck 
of one of her children. The swelling may 
appear during the night and increase greatly 
in size for a day or two, when it may be as 
large as a horse-chestnut. Such a condition 
is due to swollen lymphatic glands, which 
are usually situated just behind the jaw and 
below the ear. Occasionally the swellings 
may appear in the soft parts under the jaw. 
The glands, in the performance of their 
functions, have become infected and the 
swelling follows. The cause of the infection 
will usually be found in a lesion of the mouth 
or throat. It may sometimes be traced to 



Glands 229 

a lesion of the skin in the neighborhood of 
the swelling. Thus, the source of infection 
may be a decayed tooth, a simple abrasion 
of the mucous membrane, or an acute inflam- 
mation of the part, such as tonsillitis or 
pharyngitis. In scarlet fever and in diph- 
theria the glands are often seriously involved. 
The glandular enlargements, however, wiiich 
appear suddenly, independent of serious ill- 
ness, need cause no great anxiety. They 
terminate usually in one of two ways: they 
gradually disappear under treatment, or 
they break down and form an abscess which 
requires incision and drainage. In either 
event complete recovery follows. 

If the swellings occur in diphtheria or in 
any other infectious disease, they may con- 
stitute a grave complication. With their 
first appearance, apply cold compresses to 
the parts constantly until the physician 
arrives. 

CHRONIC ENLARGEMENT OF THE GLANDS OF THE 
NECK 

The lymphatic glands of the neck may be 
chronically enlarged as a result of tubercu- 



230 The Skin in Health 

losis, syphilis, or local infections from the 
skin, and a lowered general vitality. 

The mother usually notices a slight swelling 
of the parts, which, upon touch, gives the 
impression of a hard round body imme- 
diately beneath the skin; usually several 
of these nodules will be discovered. They 
often extend in chains down the side of the 
neck; sometimes both sides will be involved. 
Bunches of glands may also appear under 
the ear and at the angle of the jaw. They 
vary in size from a buckshot to a butternut. 

Children with a tendency to enlargement 
of these glands should be constantly under 
medical supervision. 

THE SKIN IN HEALTH 

The skin of an infant is extremely delicate 
and great care is required to keep it in a 
healthy condition. The secret of a healthy 
skin in an infant is in proper attention. It 
must be kept clean and dry. After the 
daily bath, in which no ingredient other than 
plain boiled water and Castile soap should 
enter, the baby must be carefully dried and 
the folds of the skin and flexures of the joints 



Eczema 231 

thoroughly powdered with equal parts of 
oxide of zinc and powdered starch. When 
the napkins are soiled they should be changed 
at once and the parts again washed and 
powdered. An occasional sponging, fol- 
lowed by a generous use of powder during 
very hot weather, will often prevent annoy- 
ing skin affections, such as prickly heat and 
eczema. 

ECZEMA 

Eczema, a catarrhal inflammation of the 
skin, is a disease to which young children 
are very susceptible. It appears in different 
forms, which means that there are several 
varieties of the disease. Any portion of 
the skin surface may be involved. The 
parts most frequently affected are the scalp, 
cheeks, forehead, and the flexures of the 
joints, where the skin surfaces come in con- 
tact. The cause of eczema may be from 
within or without. The external causes 
are all of the nature of irritants. A baby's 
skin is very delicate, and trifling causes will 
often produce a great deal of inflammation. 
Strong soaps, liniments, a sudden exposure 



232 Eczema 

of the moist skin to cold air, excessive perspi- 
ration, insufficient bathing, discharge from the 
ear or nose, all may cause a local irritation 
and produce the disease. Allowing a child 
to rest in a soiled napkin is a most frequent 
cause of eczema of the buttocks, a condition 
which is elsewhere referred to. The treat- 
ment of this type of the disease resolves 
itself into removing the cause and protecting 
the parts by means of a suitable ointment or 
powder. 

Among the internal causes, indigestion 
is by far the most frequent. It is not the 
delicate child who suffers most from eczema. 
In many instances the robust nursling and 
the vigorous bottle-fed baby are the sufferers. 
The child in other respects appears well, has 
a good appetite, is bright and happy, and 
shows normal development. The bright 
red and sometimes weeping area on each 
cheek, and the itching, scaly forehead, show 
clearly that something is wrong, and the 
error will usually be found in the gastro- 
intestinal tract. The food in some respect 
is unsuitable, not being properly adapted 
to the child's digestive capacity. In the 
breast-fed, regulation of the life of the 



Eczema 233 

mother as regards her diet, exercise, and 
bowel functions will often effect a cure. 

In the bottle-fed, an adjustment of the 
food to the child's age and digestive capacity 
and attention to the daily bowel evacuation 
aids materially in the treatment. Consti- 
pation, if present, must be relieved. Local 
treatment with ointments, washes, and pow- 
ders are all of little value if the cause of the 
disorder is not removed. The case may 
improve temporarily under the local treat- 
ment, but within a few days the inflammation 
reappears in full force. 

The strait-jacket. — One of the difficult 
features of treating children with eczema 
is the tendency for the child to scratch the 



FIG. 14. STRAIT-JACKET 



involved parts. This not only keeps up 
the trouble indefinitely but the nails are 
often the carriers of infection. I have seen 



234 Eczema 

not only severe dermatitis, but furunculosis 
and cellulitis develop in this way. One of 
the best means of preventing scratching is 
in the modified strait-jacket (see Fig. 14). 
The jacket is made of muslin and must be 
fitted to the patient. The child is slipped 
into the jacket feet first. The opening A 
encircles the thorax directly under the arms. 




FIG. 15. STRAIT-JACKET IN POSITION 

The opening B is closed about the neck with 
the attached tapes. The cord which is used 
to close the end of the sleeves may be tied 
to the sides of the crib or pinned to the bed- 
ding. Children readily accustom themselves 
to the position of lying on the back which 



Eczema 



235 



its use necessitates. It is no kindness to 
allow a child to further irritate the already 
badly involved surfaces. 




GATHta 

gather 

FIG. l6 MASK PATTERN 



The mask. — In facial eczema, the itching 
is often most intense. In order to effect a 
cure, scratching and rubbing, of the parts on 
any object with which the child may come 
in contact, must be prevented. The Thomas 
mask (see Fig. 16) answers this purpose ad- 
mirably. The ointment or lotion is placed 
on clean linen which rests on the involved 
parts. Over this is placed the mask. In 
Fig. 16 is represented a pattern of the mask. 



236 



Eczema 



Opening A is sufficiently large to furnish 
space for the eyes, nose, and mouth. An 




FIG. 17. MASK IN POSITION 

elastic band which will be seen to pass over 
the upper lip, draws the sides of the opening 
together, insuring protection to the cheeks, 
usually the parts chiefly involved. B and C 
pass over the top of the head and are sewed 
to D and E which pass over the ears, to 
the back of the head where they are 
united. The masks are best made of 



Hives 237 

muslin or thin old linen, and are to be 
renewed daily. 

HIVES 

The type of hives most frequently seen 
in children appears in the form of large 
wheals from one-half to one inch in diameter. 
There may be but two or three of these 
wheals, or a large portion of the body may 
be covered by them. They consist of a 
firm, flat, circumscribed, reddened eruption 
of the skin, without any definite arrange- 
ment. In addition to the skin, the mu- 
cous membrane of the tongue, mouth, and 
pharynx may be involved. In some in- 
stances the eruption appears very suddenly, 
lasts but a few hours, and quickly disap- 
pears. If the attack is of a severe nature 
new spots appear from time to time which 
behave in the same way. Hives in children 
are almost without exception due to diges- 
tive disorders. I have repeatedly known 
attacks to follow some unsuitable article 
of diet, such as cakes, strawberries, pastry, 
or nuts. Constipation may cause an attack. 

The only symptom of consequence is the 



238 Milk-Crust 

distressing itching which is always present. 
Treatment consists in the use of laxatives 
and a temporarily restricted diet. The itch- 
ing is best relieved by bathing the parts with 
a solution of carbolic acid — one teaspoon- 
ful to a pint of water. 

MILK-CRUST 

What is commonly known as milk-crust 
consists of the formation on the scalp of a 
thick layer of yellow sebaceous material. 
In addition to being unsightly it is very 
annoying to the patient on account of the 
itching which it causes. The mother usually 
assures us that the condition is not due to 
neglect. The head is washed and oiled very 
often ; but washing will neither cure nor pre- 
vent the disease. 

Milk-crust is due to an inflammation of 
the sebaceous glands of the skin. The affec- 
tion is easily relieved. The hair must be 
cut very short, and an ointment, composed 
of resorcin, forty grains, and vaseline, two 
ounces, should be spread generously over 
the diseased area and covered with a piece 
of linen which has been saturated with the 



Intertrigo 239 

ointment. Over this a fairly tight-fitting, 
home-made muslin cap should be worn to 
hold the dressing in place. The ointment 
should be applied twice daily. After three 
or four days of the treatment, during which 
time no water must touch the scalp, it may 
be gently cleansed with Castile soap and 
warm water, or with warm sweet oil. 

The whole or the greater portion of the 
crusts may be removed with the first washing. 
Some severe cases may require two or three 
repetitions of the treatment. After the 
scalp is clean, an application of the oint- 
ment at bedtime once or twice a week will 
prevent a return of the trouble. 

INTERTRIGO 

Inflammation of the skin of the thighs 
and buttocks, by some mothers erroneously 
called sprue, is often seen in quite young 
children. In the majority of cases this 
condition is due solely to neglect of the 
toilet. The child is allowed to lie in soiled 
napkins, the irritant discharges thus remain- 
ing in contact with the delicate skin, and 
inflammation and excoriation of the parts 



240 Intertrigo 

naturally follow. Children have delicate 
skins and often pass very acid urine. When 
this combination is present an inflammatory 
condition of the parts is frequently difficult 
to avoid. The management is simple, 
usually requiring only a changing of the 
napkin as soon as soiled and the generous 
use of zinc ointment. I have had very little 
success with dusting powders in such cases, 
especially in those of any degree of severity. 
After passage either from the bladder or 
bowels, the napkin should be immediately 
removed, the parts gently washed with 
Castile soap and boiled water, or, in bad 
cases, warm sterilized sweet oil may be used 
to better advantage. After the parts are 
clean, apply to the inflamed area pieces of 
clean old linen which have been covered with 
zinc ointment. If the ointment is applied 
directly to the skin the napkin soon absorbs 
it, and its application will be of no service. 
The ointment acts as a barrier between the 
irritating passages and the inflamed skin. 
Under this treatment I have repeatedly 
seen the worst cases of intertrigo recover 
in a week. 

Of course the applications must be re- 



Prickly Heat 241 

peated after each cleansing and drying. 
The ointment must be used extravagantly. 
The dressing is then applied :: the parts 
and is to be changed several times daily. 

Over this dressing the napkin is placed, and 
is to be changed several times daily. If 
the ointment is simply spread over the skin 
and the napkin applied, it will soon be ab- 
sorbed by the napkin and be c: no service. 
The urine, which is chiefly at fault, is pre- 
vented by the ointment dressings from 
coming in contact with the skin, the treat- 
ment being solely protective. At the same 
time a quantity ent : :tton is placed 

next to the genitals so as to absorb the urine 
as it is passed and thus prevent its general 
distribution over the parts. When the 
is well advanced toward recovery, scrupulous 
cleanliness and a dusting-powder coma 
of equal parts of powdered starch and oxide 
of zinc will usually be all that is required. 

PRICKLY HEAT 

In prickly heat there is an acute engorge- 
ment of the vessels of th t -glands \ 

obstruct i their outlet. Minute papules 

16 



242 Prickly Heat 

form which are reddish in color. The mild 
cases are without inflammation. When in- 
flammation develops, small vesicles also 
appear and may cover large areas of the 
body. Nearly every infant suffers from 
prickly heat in summer. It is most fre- 
quently seen on the head and neck and over 
the chest and shoulders. The patients are 
very uncomfortable and restless. There is 
evidently a great deal of burning and itching. 
The condition is caused by heat, due either 
to too much clothing or to the hot weather 
of summer; both causes may be operative. 
I have frequently seen it in winter in over- 
clad children. Most babies are overclad at 
all seasons of the year. When prickly heat 
develops, regardless of the season, it is a 
sure sign that the child has been kept too 
warm. The duration is dependent upon 
climatic conditions and also upon the treat- 
ment. I have seen cases which have existed 
for months. 

Heavy clothing and flannels are to be 
avoided. The clothing should be light in 
weight and of loose texture. In order to 
lessen the local irritation the garment worn 
next to the skin may be lined with silk, linen, 



Prickly Heat 243 

or gauze. The further means of manage- 
ment as regards both the relief afforded the 
patient and the cure of the condition, con- 
sists in the frequent application of cool water, 
in the form of either a tub-bath or sponging. 
The soda bath, the bran bath, and the starch 
bath (page 117) are all most useful. For 
purposes of sponging, a solution of bicar- 
bonate of soda should be used — one table- 
spoonful to a gallon of water. The relief 
afforded the patient depends not so much 
upon what is used in the w T ater as upon the 
fact that plenty of cool water comes in con- 
tact with the itching, burning skin. Oint- 
ments and salves are of little service here, 
as they tend to produce further maceration 
of the skin. As local applications, powders 
are preferred to lotions. A powder used 
with satisfaction in this condition is of the 
following composition : 

]J Boracic acid, 60 grains. 

Powdered starch, ) , 

~ , 1 .. e . y each 1 ounce. 

Powdered oxide of zinc, ) 

This is to be dusted freely over the involved 
surface several times daily, every hour if 
necessary. 



244 Fissures of the Anus 

FISSURES OF THE ANUS 

In children suffering from what are called 
fissures of the anus there will be found one 
or more slight tears in the mucous membrane 
just inside the anal aperture. In such cases 
there is always a history of an intestinal 
disorder, usually constipation, sometimes 
diarrhoea, the fissures having been caused 
either by a stretching of the parts by a hard, 
constipated movement, or by the frequent 
irritant passages which have caused a de- 
struction of the mucous membrane of the 
parts. 

An infant thus affected cries lustily when 
having a passage, and strains and presses 
for some time afterward. Very often the 
passage will be streaked with blood. Older 
children postpone going to stool as long as 
possible and complain greatly of pain when 
the bowels move. 

These cases will be greatly relieved by 
the correction of the intestinal derangement. 
If the child is constipated, the movements 
should be kept soft by the use of suitable 
diet and laxatives. If there is diarrhoea, 
suitable diet and medical attention are 



Boils 245 

necessary. The local treatment, which may- 
be necessary, should be carried out by a 
physician. 

BOILS 

Infants are particularly subject to boils, 
which are supposed by many to indicate 
some radical blood disorder. As a result, 
the victims are drugged and purged with 
all sorts of teas and "blood-purifiers. ,, The 
cause of the boil is very rarely from within. 
It is usually the result of a local infection 
or inoculation into the skin, the germs 
finding entrance by means of a hair follicle 
or an abrasion so small as to be invisible to 
the naked eye. A boil having formed, the 
pus is carried to other portions of the skin 
by the lymphatics, or it escapes upon the 
surface, and, in either case, other portions 
of the skin are inoculated, and a series of 
boils results. The parts most often involved 
are the head, the neck, and the shoulders, 
although they may appear upon any portion 
of the body, with the exception of the palms 
of the hands and the soles of the feet. I 
have opened one hundred and four on one 



246 Burns 

child during a period of three weeks. While 
boils are more frequently met with among 
the debilitated and weakly, they are by no 
means uncommon in the strong and other- 
wise well. Poulticing, and allowing a boil 
to open spontaneously, is calculated to pro- 
long the trouble indefinitely. A boil should 
be opened early, the pus evacuated, and the 
surrounding skin thoroughly washed with 
soap and water, when an antiseptic dressing 
composed of several thicknesses of old linen, 
which has been boiled and dried and then 
dipped into a saturated solution of boracic 
acid, answers every purpose. Not only 
the boil but the adjacent skin for several 
inches must be covered by the dressing, 
which is to be kept wet with the boracic acid 
solution. 

BURNS 

The temporary treatment of a burn of 
any degree aims at the exclusion of the air 
by the application to the injured parts of 
some non-irritating, oily substance, such as 
vaseline, zinc ointment, or sterilized sweet- 
oil. A piece of clean linen is saturated with 



Head Lice — Pediculi Capitis 247 

the ointment and placed upon the parts 
affected, and kept there until the arrival 
of the physician. 

HEAD LICE— PEDICULI CAPITIS 

Head lice, or pediculi capitis, are very 
frequently seen in out-patient and hospital 
work among children in all the larger cities. 
Occasionally other children become infected 
in school or in public conveyances who carry 
the vermin to other members of the family. 
The most successful and cleanly treatment 
consists in cutting the hair short ; this done, 
wash the head with soap and water once a 
day, and after drying moisten the scalp 
thoroughly with the following solution twice 
daily : 

Acetic acid 2 drachms. 

Sulphuric ether 3 ounces. 

Tincture of larkspur, ) . - 

. , A . . > of each 4 ounces. 

Spirits vim rect., ) 

Improvement will follow a few treatments. 
The pediculi will be killed and the nits may 
be removed with a fine-tooth comb. If 
the patient is a girl it is not absolutely 



248 Bites of Animals 

necessary to sacrifice the hair. It may be 
parted from various portions of the scalp 
and the solution applied without previous 
washing. However, if the hair is not cut, 
a much longer time will be required to 
effect a cure. 

BITES OF INSECTS 

Bites of insects in this country are rarely 
dangerous, although they sometimes cause 
great temporary disfigurement. It is quite 
difficult often to distinguish between insect 
bites and the eruption of hives. Mosquitoes 
poison some infants severely. 

Insect bites are best treated by the use 
of a solution of carbolic acid, — one-half 
teaspoonful to a pint of w^ater. This is 
applied by means of old linen which is kept 
saturated with the solution. 

BITES OF ANIMALS 

Bites of animals rarely amount to more 
than an incised wound from any other cause, 
and the treatment required is practically 
the same. When a child is bitten by a dog 



Fever 249 

or a cat the parents are greatly alar: 
lest the child develop hydrophobia. If, 
however, they will remember that dogs bite 
thousands of people every year and no harm 
comes from it, if they will remember that a 
mad dog is of the rarest occurrence, they 
will waste much less good nerve force upon 
what is usually a trifling matter. In case 
of a bite of any animal, dissolve one tea- 
spoonful of carbolic acid in one pint of water, 
and keep the parts moist with the solution, 
using only clean linen for its application to 
the wound. The physician, who shoul 
called at once, will advise further treatment 
if needed. 

FEVER 

By fever we understand an elevation of 
the temperature of the body above the 
normal, which in an infant is 99 F. + by 
rectum. Fever, however, does not con- 
stitute disease. It is nothing more or less 
than a symptom, but it always means that 
something is wrong with the baby. It may 
be due to a slight attack of indigestion, the 
eruption of teeth, or to the beginning of 



250 Fever 

scarlet fever, diphtheria, or some other 
disease. Children develop fever much more 
readily than adults, and it is of less signi- 
ficance in them. A child with fever that 
is appreciable to the touch of the mother 
will usually register a temperature of 100. 5 
-10 1. 5 F. While such a temperature is 
by no means alarming, its cause should be 
discovered. In the absence of a clinical 
thermometer, in order to examine a baby 
for fever, place upon the abdomen the palm 
of a hand which has been previously warmed. 
Examination of a child's hands, head, and 
feet furnishes us very inexact means of 
judging as to the question of fever. Many 
times these parts will be cold when the 
thermometer registers a temperature of 104 
or 10 5 F. Every young mother should pos- 
sess, and know how to use, a clinical ther- 
mometer. In case of sudden high fever, — 
104 to 105 P., — from any cause, the mother 
cannot make a mistake in giving an alcohol 
and water sponge-bath at a temperature of 
8 5 F. One part of alcohol may be added 
to 3 parts of water and the child sponged 
for twenty minutes. If necessary the spong- 
ing may be repeated every two or three 



Malaria 251 

hours; this will keep the child comfortable 
until the arrival of the physician and per- 
haps prevent unpleasant complications. In 
case of fever the nourishment should always 
be reduced at once; if the child is on the 
bottle, reduce the strength of the food one- 
half by the addition of boiled water. If 
the child is nursed, reduce the duration of 
each nursing period one-third. Children 
with fever can always have plenty of cold 
boiled water to drink. Mothers must re- 
member that it is not the fever per se t but 
the condition of the patient, which governs 
us in our treatment. In scarlet fever and 
pneumonia, a temperature of 102 to 104 F. 
is expected, and need cause no alarm. 

MALARIA 

Children in New York City and vicinity 
occasionally suffer from malarial fever. 
Fewer cases come under my observation 
now than formerly. The disease manifests 
itself in three different sets of symptoms. 
The mild form is most frequently seen, and 
will be the first considered. 

The first signs of the illness are drowsi- 



252 Malaria 

ness, languor, disinclination to play, and 
loss of appetite. In addition, such a child 
is apt to be peevish and fretful; he falls 
asleep at unusual times during the day. 
The sleep at night is often disturbed, and 
he generally sleeps later in the morning. 
There is a little fever, — so slight that it is 
not appreciable to the touch. These symp- 
toms are followed by pallor and loss of weight. 
Such a condition may exist for several weeks 
without the development of more active 
symptoms of the disease. 

In the more typical cases, the fever, lan- 
guor, and drowsiness will appear at a definite 
time each day,' — usually from three to five 
o'clock in the afternoon. The child wakes 
the following morning apparently well, but 
at about the same hour in the afternoon 
the symptoms are repeated. There is always 
a distinct periodicity in the symptoms. In 
some cases the child will be ill every second 
day, but at the same hour. In other cases 
the symptoms are still more characteristic 
and are easily recognized. At a certain 
time every day, or perhaps every second 
or third day, there will be a chill and a 
rapid rise in temperature, followed by a 



Tuberculosis 253 

profuse perspiration, during which the fever 
subsides. 

I recently treated a little girl five years 
of age who had a chill every second day at 
eleven o'clock in the morning. The fever 
rose rapidly, until at one o'clock it was 106 ; 
at 3.30 the temperature was normal, and 
the child felt perfectly well. This continued 
for one week. 

The diagnosis in the first class of cases is 
by no means easy. In many instances the 
nature of the illness is not discovered and 
the child is treated for various imaginary 
ills. 

The usual treatment of malaria in children 
is by the use of quinine, or by a change of 
climate. The majority of the cases recover 
satisfactorily under quinine, but it should 
never be given without a physician's order. 
The indiscriminate giving of quinine when- 
ever a child falls ill cannot be too strongly 
condemned. 

TUBERCULOSIS 

Tuberculosis is an infectious disease which 
carries off one-seventh of the population of 



254 Tuberculosis 

the earth. Children are very susceptible 
to the infection. The disease is caused by 
the entrance into the system of a micro- 
organism known as the tubercle bacillus. 
Tuberculosis is not inherited. The disease 
always comes from without, as does typhoid 
fever or diphtheria. We often see parents 
and children in turn sicken and die with 
this disease. This does not necessarily mean 
heredity, however. It means that there is 
a family condition of constitution which 
furnishes a favorable soil for the develop- 
ment of the bacillus. If all who swallowed 
or inhaled the tubercle bacillus became 
tubercular, the earth would be depopulated 
in a very few years. We have all taken the 
tubercle bacillus into our bodies at some 
time, probably mam' times. In one indi- 
vidual the germ finds a favorable soil and 
flourishes; in another, unfavorable condi- 
tions, — health and vigor of constitution, — 
and it dies. The usual means of infection 
is through the inspired air by the inhalation 
of the infected dust from the public convey- 
ances, from the street, or from infected 
dwellings. Infection may also take place 
by direct contact through kissing. The 



Tuberculosis 255 

bacillus may be swallowed with food or 
drink which has been contaminated. 

Almost every portion of the body may 
become the seat of the tubercular process. 
When the micro-organism attacks the lungs, 
it produces what is known as consumption, 
or pulmonary tuberculosis. When the cov- 
ering of the brain is involved, the child has 
tubercular meningitis. When the hip-joint 
is attacked, hip-disease follows. When the 
spine is attacked, it produces what is known 
as Pott's disease. When the glands of the 
neck are infected, scrofulous glands or tuber- 
cular adenitis is the outcome. Tubercular 
disease of the knee is commonly known as 
white swelling. These are the parts which 
are most frequently the seat of the tuber- 
cular process. With less frequency the 
bacillus attacks the bladder, the kidneys, 
the skin, the intestines, the mesenteric glands, 
and the peritoneum. 

In institutions and among the poor, what 
is known as general tuberculosis causes the 
death of many infants. At autopsy they 
show an involvement of nearly all the in- 
ternal organs. Tuberculosis in children is 
always a very serious disease, but it is not 



256 Rickets 

necessarily fatal ; many cases recover. When 
the disease involves the spine, hip-joint, or 
knee-joint, or the glands of the neck, the 
prognosis as regards life is usually good. 
When the brain is attacked, it is always fatal. 
In tubercular disease of the lungs in very 
young children the prognosis is very grave. 
Many older children — those from seven to 
eight years of age — recover if the disease 
has not progressed too far before coming 
under treatment. The important features 
in the management of these cases are : change 
to a dry climate at an elevation of one thou- 
sand to fifteen hundred feet, with close atten- 
tion to hygiene and a carefully regulated diet 
in which there should be a generous allowance 
of meat, eggs, and milk. 

RICKETS 

Rickets is a constitutional disease due 
to malnutrition. A child with rickets either 
has not received suitable nourishment, or, 
if he has received it, it has not been assimi- 
lated. Lack of nourishment manifests itself 
in characteristic changes in the bones, mus- 
cles, and in the nervous system. In addition 



Rickets 257 

to their physical characteristics, children 
with this disease may show delayed mental 
development. A rachitic child is usually 
under weight and undersized, particularly 
as regards length. The head is ill-shaped, 
the enlargement of certain bones of the skull 
giving the head a square appearance. The 
sutures and fontanelle close very late. I 
have seen the fontanelle still open at the 
fourth year. The teeth are cut late, are apt 
to be soft, and decay early. Many rachitic 
children do not get the first teeth until after 
the twelfth month is passed. The chest is 
narrow and depressed at the sides, and along 
its anterior portion, at the junction of the 
costal cartilages with the ribs, a row of 
nodules can be traced. The ends of the 
long bones, particularly at the wrists and 
ankles, are very much enlarged. In many 
cases this enlargement is so great that it 
produces quite a deformity. Often the legs 
are curved, a condition known as "bow- 
legs." The spine is weak and in severe 
cases the child is unable to sit erect. Spinal 
curvature is frequently seen in these children. 
The abdomen is usually very prominent. 
The malnutrition is further shown bv the 



258 Rickets 

flabby, poorly developed muscles, by the 
tendency to perspiration, particularly about 
the head, and by the unstable nervous sys- 
tem. These children are restless, irritable, 
and hard to please, and they have convul- 
sions under slight provocation. Not all 
rachitic children are below weight; some 
are quite fat, but pale and flabby. The 
changes in the bones, however, are similar 
in both types. In addition to the charac- 
teristics noted, rachitic children possess 
feeble powers of resistance. They are prone 
to catarrhal affections of the respiratory 
and intestinal tracts. In many instances, 
they teeth late and with much difficulty. 
On account of their enfeebled condition and 
lack of resistance, illness in a rachitic child 
is apt to be tedious, if not serious. 

The prevention of rickets depends upon 
proper feeding. Condensed milk and the 
proprietary meal foods are responsible for 
a large majority of the cases. Proper man- 
agement requires suitable food, cleanliness, 
fresh air, and cod-liver oil. By "suitable 
food" is meant good milk for children under 
one year, to which meat and eggs are added 
as soon as they can be digested — usually 



Scurvy 259 

after the twelfth month. For very rachitic 
children I order also one brine bath daily. 

SCURVY 

Scurvy is a disease of quite frequent 
occurrence among bottle-fed children. It 
is characterized by pain in one or more of 
the joints of the long bones, with or without 
swelling of the involved parts and discolored, 
spongy, or bleeding gums. Hemorrhages 
into the skin sometimes occur, which give 
the child a peculiar mottled appearance. 
The disease is often mistaken for rheuma- 
tism because of the swollen and painful 
joints. If the case is a very severe one it 
may resemble paralysis in some of its aspects. 

The disease is due to errors in nutrition. 
The great majority of the cases develop in 
those who are being fed on proprietary meal 
foods, condensed milk, and overcooked cows' 
milk. 

Among the author's sixty-four cases, one 
symptom was always present: They all 
showed evidences of faulty nutrition; they 
also presented another symptom in common 
which was the earliest active manifestation of 



260 Scurvy 

the disease, and that was pain. The child 
that has been playful, active, and has enjoyed 
attention, suddenly undergoes a change — 
he prefers to rest in the crib or carriage, 
cries when handled, and refuses to play. 
Often the first signs of trouble will be noticed 
when changing the napkin or putting on 
the shoes or stockings. The movement of 
the diseased parts causes pain and the child 
cries lustily. If he is undressed and rests 
on his back, the affected limb in all prob- 
ability will remain motionless, while its 
companion may be moved freely. 

The symptom of pain appears before the 
swelling of the joints, which is sure to follow 
in case the disease is not recognized early 
and treated properly. Another character- 
istic symptom is the swollen, congested, and 
bleeding gums about the upper incisor teeth. 
This condition is sometimes seen early in 
the attack, but it is usually a later symptom. 
Hemorrhages into the skin are of compara- 
tively infrequent occurrence. 

Scurvy uncomplicated is not accompanied 
by fever. Acute articular rheumatism is 
always accompanied by fever. Rheuma- 
tism is rare in children under two years of 



Rheumatism 261 

age ; scurvy is rare in children over two years 
of age. There is no excuse for an error in 
diagnosis between the two affections. 

The treatment is: fresh cows' milk, beef 
juice, and orange juice. For a child one 
year of age the juice of one orange should 
be given daily. Under proper treatment 
the average case will be well in a week or 
ten days, improvement being noticed in 
from twenty-four to forty-eight hours after 
beginning the treatment. 

RHEUMATISM 

Rheumatism is a disease of very grave 
import and of rather frequent occurrence 
among children after the third year. Under 
the second year it is of the rarest occurrence. 
At this age scurvy is frequently diagnosed 
as rheumatism. It may appear in all de- 
grees of severity. The mild attacks are 
often so slight that a physician is not con- 
sulted and the diagnosis of rheumatism 
never made. Such cases are often mistaken 
for sprains and so-called ' k gro wing-pains.' ' 
Aside from this mild type we have the disease 
in all degrees of severity. The severe artic- 



262 Grippe 

ular form known as inflammatory rheu- 
matism, is that in which the child, with high 
fever, reddened, swollen joints, dreads your 
approach to the bedside and begs you not 
to touch him. There can be no attack of 
rheumatism so mild that it should be ignored. 
Every child ill with this disease is in danger 
of heart complications which may make him 
an invalid for life. Probably four-fifths of 
the cases of valvular heart disease in adults 
are due to attacks of rheumatism during 
childhood, and in many instances the disease 
of the heart is not recognized until long after 
the rheumatic attack. In every case of 
rheumatism the heart should be examined 
and properly treated. Heart involvement 
is as liable to develop in the mild as in the 
severe attacks. In some cases it is the only 
evidence of the presence of rheumatism. 
Children of rheumatic parentages and those 
who show rheumatic tendencies should be 
given a very low sugar diet with red meat 
not over three times a week. 

GRIPPE 

Grippe is a disease very prevalent among 



Grippe 263 

ehiliren durir.^ the ::i:ier months. It is iue 
to a micro-organism which is usually taken 
into the system with the inspired air. There 
are four types of the disease to be seen in 
children. 

In the most common type the respiratory 
passages are the parts chiefly involved. The 
symptoms resemble in some respects those 
of a common cold. There is r unning at Hie 
nose, cough, sore throat, and, generally, 
bronchitis. There is a higher fever, how- 
t : . than can be explained by the catarrhal 
symptoms, greater muscular weakness, and 
greater prostration. If uncomplicated, the 
disease usually runs its course in from five 
to eight days. The complications to be es- 
pecially dreaded are bronchitis, pneumonia, 
and otitis 

The next most frequent type of grippe is 
the muscular. There are fever, headache, 
loss of appetite, prostration, and great mus- 
cular weakness. There is little or no involve- 
ment of the respiratory tra:: 

The third type includes the cases in which 
the intestinal symptoms predominate. I 
saw about twenty of these cases during 
the winter of 1890-91. The children were 



264 Grippe 

taken suddenly with fever, prostration, and 
diarrhoea which was very hard to control. 
There were from eight to sixteen green, 
watery passages daily, containing a moderate 
amount of mucus, streaked with blood. 
There were also slight cough and coryza, 
with considerable congestion of the throat. 

In the fourth type the nervous system 
is chiefly affected. These patients have the 
fever and muscular soreness common to all 
varieties, with the prominent symptom — 
excessive irritability. In some cases there 
seems to be almost entire loss of self-control. 
The patients are peevish, fretful, depressed 
and hysterical by turn. They cannot bear 
the slightest noise, and sleep only when under 
the influence of drugs. 

The severe cases, however, have two 
symptoms common to all' — fever and intense 
prostration; prostration and weakness out 
of proportion to all objective symptoms are 
the peculiar characteristics of grippe. I 
have lost two patients aged, respectively, 
three and four months, in both of which the 
system was completely overwhelmed by the 
virulence of the grippe poison. Both chil- 
dren died in less than twenty-four hours, 



Convulsions 265 

apparently from exhaustion. Post-mortem 
examination failed to detect in either case 
any organic change sufficient to cause death. 
A very unpleasant feature of grippe is the 
wretched physical condition in which the 
patient is often left after the acute symptoms 
have disappeared. Weeks of the most care- 
ful treatment will frequently be required 
to restore his previous good health. There 
is no specific treatment for this disease. 
Every case must be treated according to 
the symptoms presented. For those which 
fail to make prompt recovery, a change of 
climate should be advised. Many of my 
patients have done surprisingly well at 
Lakewood, or at Atlantic City. 

CONVULSIONS 

A convulsion is a temporary loss of 
consciousness, associated with rhythmical 
contractions of various muscles of the body. 
Rachitic, delicate children, and those suf- 
fering from malnutrition in any form are 
predisposed to convulsions. Disturbances in 
the gastro-intestinal tract, due to errors in 
feeding, have been the cause in ninety-five 



266 Convulsions 

per cent, of my cases. Nearly all were seen 
among the badly, bottle-fed or in those 
beyond the bottle age who had been given 
food unsuited to their years. I have fre- 
quently known seizures to follow an unusual 
indulgence in cake, pie, or fruit. Exces- 
sively high fever may be a cause of con- 
vulsions. Pneumonia, meningitis, and 
contagious diseases are sometimes ushered 
in by convulsions. Heat prostration and 
worms may be mentioned as infrequent 
causes. A patient of mine, — a boy three 
years old, — had repeated convulsions until 
he was relieved of forty-three large round 
worms. According to my observation, den- 
tition is rarely an immediate cause. The 
dentition period covers eighteen months, 
and children often have convulsions during 
this time; a thorough examination of the 
patient, however, will usually reveal the 
seat of the trouble in the intestinal canal 
or stomach. Dentition may indirectly be a 
factor. A few years ago a mother insisted 
that I should lance the healthy gums of a 
girl eighteen months of age, who repeatedly 
had convulsions. This I refused to do, and 
ordered, instead, two teaspoonfuls of castor- 



Convulsions 267 

oil. The child passed one-quarter of a par- 
tially masticated orange and the convulsions 
ceased. 

When a child is attacked, prompt action 
is necessary. The family physician should 
be sent for and the patient placed at once in 
a mustard bath at a temperature of 105 F. ; 
an even tablespoonful of mustard should be 
added to five gallons of water. The patient 
should not be allowed to remain in the bath 
over ten minutes, when he should be removed 
and dried vigorously. If possible, the child's 
temperature should be taken while in the 
bath, and if above 102 F. (in convulsions 
it usually ranges between 104 and 106 F.) 
the temperature of the water should be low- 
ered to 75 or 8o° F. by the addition of ice 
or cold water. Watch the effect of the cool- 
ing of the bath upon the child's temperature, 
and when it is reduced to 10 1° P., remove 
him. The temperature in convulsions should 
always be noted. To my mind the high 
fever has oftentimes a great deal to do with 
the seizure. Not long since I was called to 
see a child in convulsions. Upon my arrival 
I learned that he had been put into a hot 
bath at no° F., and kept there fifteen 



268 Convulsions 

minutes, but the child showed no signs of 
improvement. The temperature was taken 
while in the bath, and registered iii° F., 
as high as the thermometer would register. 
In this case the hot bath was the worst 
means of treatment that could be devised. 
There is no advantage in making the water 
hotter than 105 F. In the bath, or imme- 
diately upon removal, give an enema of soap 
and water so as to insure a movement of 
the bowels as soon as possible. As soon as 
the child can swallow, one or two teaspoon- 
fuls of castor-oil should be given. If it is 
known that the child has taken something 
indigestible, a teaspoonful of syrup of ipecac 
should be given, and repeated in twenty 
minutes if vomiting does not follow. The 
convulsion is very apt to be repeated if the 
cause is not removed. The patient should 
not be held on the lap. He should be placed 
in his crib and kept very quiet. Cold cloths 
should be applied to the head and a hot- 
water bag to the feet. No solid food or 
milk should be given for twenty-four hours ; 
broths and barley-water should constitute 
the diet. During the next few days there 
should be no excitement, and the physician's 



Colic 269 

orders regarding medication and diet should 
be carefully carried out. 

COLIC 

There are few children who reach the age 
of one year without having suffered from 
colic. Infants in the earliest months of life 
are particularly susceptible to such attacks. 
The majority of cases are seen in children 
under five months of age, although the seiz- 
ures may continue until a much later period. 
During the attack the child cries violently, 
becomes red in the face, clinches its fists, 
draws up its legs, doubles up its body, and 
straightens out again. The abdomen is 
hard, often distended, and the hands and 
feet are cold. The child rests a few moments 
and cries again. Often all attempts at com- 
forting him fail. An attack may continue 
from a few moments to an hour or more, 
perhaps until the child sleeps from exhaus- 
tion. I have had children brought to me 
for treatment who were so hoarse from crying 
that they could scarcely utter a sound. There 
may be several attacks a day after the feed- 
ings or they may not appear until evening. 



270 Colic 

Afternoon or evening colic is probably most 
frequent. These cases are easily explained. 
The overtaxed stomach has done its work 
fairly well early in the day, but as the im- 
proper, frequent feedings follow, it becomes 
tired and refuses to work ''overtime." Dur- 
ing the night some rest is obtained, but the 
following day the entire programme is re- 
peated. So-called colicky children are often 
otherwise perfectly well. If the trouble is 
not particularly severe, the}' may be well- 
nourished and well-behaved babies when 
not in pain. In the severe cases there is apt 
to be evidence of marked malnutrition. It 
is often remarked that "a baby must do 
just so much crying," and nothing is done 
to relieve it. If one baby cries more than 
another it is because he suffers more. A 
baby rarely cries unless he is uncomfortable 
or in pain. He may cry while his clothing 
is being changed because it disturbs him; 
he will cry from cold, hunger, from the effects 
of a misdirected pin, or from pain of any 
nature, but never without any reason. The 
general tendency of the child is to play, to 
smile and be happy. When this is not the 
case something is wrong. 



Colic 271 

Colic in every instance means indigestion. 
It means that, whether breast-fed or bottle- 
fed, the food is not suitable, — is not adapted 
to the child's digestive powers, or not prop- 
erly given. The child who suffers from 
habitual colic is usually constipated. It 
has been my experience that the chief error 
in the diet causing the colic was the excess 
of the proteid — the curd-forming element in 
the milk. It is thus practically useless to 
give carminatives and soothing syrups, and 
other remedies of a sedative nature, except- 
ing for the immediate effects. Whatever error 
may exist in the feeding must be corrected. 
If the patient is a breast-baby we must treat 
the mother, — the source of the child's nour- 
ishment. Nursing mothers of colicky babies 
are usually of sedentary habits, hearty eaters, 
and constipated. Our first step must be 
to cure the constipation of the mother. She 
should have one full, free passage from the 
bowels daily. She should exercise in mod- 
eration in the open air: a walk of an hour 
or two in the morning, and an hour in the 
afternoon, will be most beneficial. Her diet 
should consist of fresh meat, poultry, fish, 
cereals, soups, baked potato, green vege- 



272 Colic 

tables, and stewed fruit. Coffee may be 
taken in moderation; milk, cocoa, chocolate, 
and water may be taken freely. A nursing 
mother should drink no tea. It is a popular 
idea that tea is a very necessary article for 
the nursing mother. Hardly a week passes 
but I hear from the out-patient mother of 
a sick breast-baby that she is drinking from 
one to two gallons of tea a day. The tea is 
kept "on the back of the. stove," so as to be 
ready for use at any time. I have relieved 
many cases of colic in the child simply by 
curing the mother's constipation and regu- 
lating her diet. 

Menstruation often causes temporary at- 
tacks of colic and other digestive disturb- 
ances in the child. Fright, anger, worry, 
or anything in the nature of a shock in the 
mother will often seriously affect the child's 
digestion. In short, when the nursing child 
suffers thus from digestive derangements, 
the error, nine times out of ten, rests with 
the mother. The trouble is rarely with the 
child. 

As previously stated, habitual colic in 
the bottle-fed tells us that we are not giving 
the child a suitable food, or that we are 



Colic 273 

not giving a suitable food properly. The 
food as a whole may be too strong or too 
weak. It may be given too frequently. 
If cows' milk is the diet, the error is often 
due to improper modification. The proteid 
will usually be found in excess ; not in excess, 
perhaps, for the average child, but in excess 
for the patient in question. There can be 
no set rules for feeding or definite formulae 
for various ages that are infallible. The 
food of artificially fed children must be 
adapted to meet their individual require- 
ments. The treatment of habitual colic in 
the bottle-fed consists in rendering the food 
suitable. 

For the relief of immediate attacks, an 
injection of from six to eight ounces of water 
at no° F., to which one-half teaspoonful of 
salt has been added, will often be of service. 
Five to eight drops of gin in a teaspoonful of 
warm w r ater, by mouth, is sometimes useful. 
Two-drop doses of Hoffmann's Anodyne in 
two teaspoonfuls of hot water will frequently 
cut short a severe attack. Both the gin and 
the anodyne may be repeated in one-half 
hour if relief is not obtained. If the attack 
is prolonged, a hot-water bag should be 
18 



274 Constipation 

placed at the feet, and flannels wrung out of 
hot water applied to the abdomen. Often- 
times, in order that the digestive organs may- 
have a complete rest, it is advisable to dis- 
continue the regular food for a few hours, 
and give barley-water as a substitute. 

CONSTIPATION 

Among the derangements of the young, 
there are few which give more annoyance 
or are harder to manage successfully than 
constipation. The causes of the trouble are 
anatomical and dietetic. The comparatively 
long large intestine folded upon itself in 
the narrow pelvis offers an obstruction to the 
free passage of the intestinal contents. The 
lack of development of the muscular struc- 
ture of the intestine is also a cause. Deficient 
nerve power, due to lack of development of 
the sympathetic nervous system, is thought 
by many to be an important factor. In all 
probability all these agents may be regarded 
as predisposing causes of constipation. The 
chief cause of constipation, however, accord- 
ing to my observation, is the proteid (the 
curd) in the child's milk. When the amount 



Constipation 275 

of proteid is excessive, — a higher percentage 
than normal, — the child will be constipated. 
A child fed on a normal proteid with a low 
fat will also probably become constipated 
on a milk perfectly adapted, because of the 
difficulty of digesting cows' -milk proteid, or 
because the heating of the milk is carried 
too far. 

Management in the breast-fed. — Among the 
breast-fed, the dietetic management of this 
disorder is difficult, for it is hard to change 
the character of the mother's milk. Much 
may be done, however. Inquiry into the 
daily life of the mother will usually disclose 
sedentary habits, a good appetite, a fond- 
ness for tea, and, probably, constipation. An 
examination of the milk of these mothers 
will show that the normal proportions of 
fat, proteid, and sugar are not maintained. 
The percentage of proteid is usually found 
to be higher than normal, with low or normal 
fat. 

The first step in the treatment is the regu- 
lation of the habits of the mother. The 
bowels should be evacuated daily, with a 
laxative, if necessary. She should be placed 
on a diet of fresh meat, fresh vegetables, and 



276 Constipation 

fruit. A malt liquor with luncheon or dinner 
is also sometimes recommended. She is 
instructed to take at least three hours' exer- 
cise daily in the open air. This regime will 
diminish the proteid and increase the fat in 
her milk, and not only relieve constipation 
in the child, but insure better nourishment 
and a later weaning than would otherwise 
be possible. The treatment of the mother is 
all that is necessary in a considerable num- 
ber of cases, but when this fails, the child 
demands attention. 

In treating the child my first step is to 
give cream; not cream purchased as such, 
but cream which rises upon the best milk 
obtainable. I give from one-half to two 
teaspoonfuls in quite warm water imme- 
diately before nursing. The use of the gluten 
suppository at the same hour for several 
consecutive days will do much to establish 
the habit of a passage at a regular hour each 
day. 

In case the cream does not agree with the 
child or is ineffective, pure cod-liver oil — 
fifteen to thirty drops three or four times 
a day, or one teaspoonful of sweet oil two 
or three times a day — may prove beneficial. 



Constipation 277 

When these measures fail, as they will in a 
small number of cases, further medication 
will be required. 

Management in the bottle-fed. — The treat- 
ment of bottle-fed and " runabout' ' children 
is much easier and the results more satis- 
factory. It is, moreover, very simple, and 
resolves itself largely into a manipulation 
of the fat and the proteid. Given a bottle- 
fed child, six months of age, suffering from 
obstinate constipation, and the proteid 
should at once be cut down to a minimum 
by prescribing a cream, water, and sugar 
mixture. This should be given raw, if prac- 
ticable. A 16-per-cent. cream is desired. 
Allow the milk which is delivered in bottles 
at about six o'clock in the morning to remain 
in the refrigerator until noon, when all the 
cream is removed. If the milk is good, the 
cream will contain approximately 16 per 
cent, of fat ; if it deviates from this figure, 
the percentage will probably be lower. I 
use the pint (sixteen ounces) for a standard. 
If we mix one ounce of this 16-per-cent. 
cream with fifteen ounces of water, we will 
have a i-per-cent. fat mixture. If two ounces 
of cream are mixed with fourteen ounces of 



278 Constipation 

water, a 2-per-cent. fat mixture will result} 
if four ounces of cream with twelve ounces 
of water, we will have a 4-per-cent. fat mix- 
ture. But our 16-per-cent. cream contains 
more than fat. It contains also, approxi- 
mately, 3.2 per cent, proteid and 3.2 per cent, 
sugar. If, then, w^e are to prepare a food 
for this six months' constipated baby, we 
need a high fat mixture, — four per cent.,— 
with a low proteid. In order to obtain it, 
we use four ounces of cream and twelve 
ounces of water. This, as will easily be 
seen, will furnish us a 4-per-cent. fat, 8-per- 
cent, proteid, and 8-tenths-per-cent. sugar. 
The fat is as high as we wish it, the proteid 
low where it ought to be, but the sugar is 
too low T , and this we increase by the ad- 
dition of milk sugar or cane sugar. 

A word about the low proteid — .8 of one 
per cent. Compared with the mother's milk 
it is low, but w T e must remember that in 
our modifications we are not dealing with 
mothers' milk. In many cases it is unwise 
to attempt to give as high a proteid as that 
contained in mothers' milk, for the reason 
that it is more difficult of digestion, and, 
by reason of its higher nutritive properties, 



Constipation 279 

it is not required. In case the reduction 
of the proteid is impracticable, or does not 
furnish relief, I add to each feeding of the 
cream or milk mixture one or two teaspoon- 
fuls of Mellin's food or malted milk, which 
will often act as a satisfactory laxative. 
One feeding daily of malted milk, which 
replaces the customary feeding, is another 
means of relieving constipation in the bottle- 
fed. In older children, — eight to twelve 
months of age, — cream diluted with water 
is often given with oatmeal jelly, — one or 
two tablespoonfuls to each feeding. It is 
extremely rare for a case to resist this treat- 
ment, and when it happens I usually find 
the stool soft when voided, deficient peri- 
stalsis being, doubtless, the cause of con- 
stipation. In such cases medication is 
required. The sweet oil as advised for the 
breast-fed may also be used here. 

Management in older children. — In "run- 
about " children the use of cream and water 
mixtures, rare meat, green vegetables, stewed 
fruit, zwieback, and bran biscuit renders 
the management of constipation exceedingly 
simple. The meals must be given at regular 
intervals, and crackers and white bread 



280 Constipation 

excluded. Bran biscuit from Stanford's, 79th 
Street and Broadway, New York, and whole 
wheat en bread may be used with advantage. 
The more the milk is heated the greater its 
constipating effects. 

It is our hope in treating constipation to 
relieve the patient by the dietetic measures 
above suggested. When these fail, we must 
resort to other means. Enemas and sup- 
positories may be used occasionally, but 
the child should not become accustomed to 
them. In the severe cases which resist die- 
tetic treatment, the outlook for an early 
recovery is not promising. In such cases 
the use of an enema of olive oil at bedtime 
has proven very satisfactory. A small 
amount of the oil, two to three ounces, is 
introduced through a large catheter, No. 18 
American (male), which is inserted ten or 
twelve inches, the catheter being attached 
to a bulb syringe with a capacity of six ounces 
(see Fig. 18). An evacuation is not desired 
until the following morning, when the child 
is placed at stool after his breakfast and al- 
lowed to remain fifteen minutes. If no evacu- 
ation occurs at the end of this time, a slight 
stimulation in the use of a suppositorv or 



Constipation 



2»I 



soap-suds may be used to bring it about. 
In a comparatively few days usually the 
morning evacuation takes place without 
assistance. The oil should be continued 




FIG. 1 8. THE BULB SYRINGE 

for several days, when it may be omitted 
one night in seven. When an evacuation 
follows the next morning, it may be omit- 
ted one night in five. In this way the 
oil may be gradually lessened until it is 
no longer required. In some children a 
small amount of the oil will be passed 
during the night. These should wear a 
napkin. 



282 Vaccination 

VACCINATION 

Every baby in fair health should be vac- 
cinated not later than the third month — 
before any trouble incident to dentition 
may arise ; for the younger the child, the less 
the constitutional disturbance. Vaccina- 
tion in a child two to three months of age 
causes practically no illness whatever. Both 
sexes should be vaccinated on the outer 
side of the calf of the leg: girls, because the 
resulting scar on the arm may be regarded, 
in later life, as a disfigurement; and both 
boys and girls, because when the sore is on 
the leg it is more easily cared for. In dress- 
ing and undressing a child, the arm has to 
be manipulated to a considerable extent, 
thus causing more or less discomfort. The 
wound should be kept covered with a ster- 
ilized gauze bandage until the crust falls, 
leaving the dry pink skin underneath. Tub 
bathing should be discontinued until this 
takes place. 

Vaccination shields are all worse than 
useless; they are often positively harmful, 
for they usually become displaced and may 
irritate and infect the sore. When unpleas- 



Vaccination 283 

ant results follow the vaccination, the virus 
is rarely at fault. The infection is usually- 
due to carelessness or to uncleanliness in 
the treatment of the wound. 

Vaccination will always be considered by 
people wlio enjoy the possession of an ordi- 
nary amount of knowledge and a moderate 
amount of common-sense as one of the great- 
est discoveries of medical science. Since its 
discovery by Jenner, as statistics show, mil- 
lions of lives have been saved by vaccination. 
It would seem strange that one should feel 
it necessary to speak in defence of a measure 
which has been of such incalculable value 
to the human race, but there are a noisy lot 
of mentally incompetent anti-vaccinationists, 
who are not without influence among their 
kind and the otherwise ignorant, upon whom 
the following statistics by Allen (Pediatrics, 
February, 1900) would produce no effect. 

In 187 1, Germany lost one hundred and 
forty-three thousand lives by smallpox; in 
1874, a law was enacted making vaccination 
obligatory during the first year of life and 
compelling its repetition during the tenth 
year. The result was that the disease almost 
entirely disappeared. At the present time 



284 Bed-Wetting 

the loss of life from this disease throughout 
the empire is scarcely one hundred a year. 
At the time of the Franco-Prussian War, 
the entire German Army was re-vaccinated ; 
while in the French Army, vaccination being 
optional, comparatively few were vaccinated. 
Both armies were attacked by smallpox, the 
French losing twenty-three thousand men, 
the German, two hundred and seventy-eight. 
With such statistics how can there be any 
plausibility in the argument of the anti- 
vaccinationists? 

BED-WETTING 

The urine is voided involuntarily by most 
children until well into the second year. If 
the child is carefully trained, the function 
of urination may be under perfect control 
during the waking hours by the end of the 
first year. We hear now and then of a child 
who urinates voluntarily at the age of six 
months. Such children are rare. The urine 
is passed normally during sleep until the 
child is two and one-half or three years of 
age. In many this will be controlled at the 
end of the second year, but I do not regard 



Bed-Wetting 285 

the lack of control as an abnormality until 
the third year is reached. If the urine is 
passed involuntarily after the child is three 
years old, a physician should be consulted, 
not necessarily to give drugs, but to instruct 
the mother as to the diet and general hygiene. 
Incontinence of urine may be due to a 
great variety of causes, among which may 
be mentioned a highly acid urine, stone in 
the bladder, which is of comparatively rare 
occurrence, adenoids, thread-worms, con- 
stipation, inflammation of the vulva and 
vagina in girls, and tightly adherent foreskin 
in boys. By far the greatest number of 
cases, however, are due to a lack of develop- 
ment of the nervous system and, in addition, 
a bad habit. Not infrequently the trouble 
is caused by too freely indulging in water 
and milk late in the afternoon and during 
the night. It is rarely a symptom of kidney 
or bladder disease. The relief of the invet- 
erate bed-wetter of five or six years of age 
is often most difficult. The child must be 
examined by a physician to determine that 
there is no local cause for the trouble. If 
no such cause is found, well-directed medi- 
cation, with the mother's co-operation, will 



286 Bed-Wetting 

usually relieve the patient, although it may 
require months to do it. In the cases of only 
occasional bed-wetting, and with younger 
patients, the mother alone can often accom- 
plish considerable. No water or milk should 
be given after four o'clock p.m. The child 
should have a dry supper, for which I would 
suggest farina, hominy, or rice, any of which 
may be served with butter and a little sugar. 
If the child will not take the cereals without 
milk, a very little may be added. This with 
stewed fruit and a piece of bread is sufficient. 
The child's bedclothing should be light, and 
he should be made to sleep on his side, not 
on his back. In order to prevent the child 
resting on his back, tie a piece of any thin 
goods about the body, with a large knot 
between the shoulders. The child should 
always be taken up at ten or eleven o'clock 
and made to urinate. 

If there is phimosis, vaginitis, thread- 
worms, or any local disorders, treatment 
of the local conditions may effect a cure. 

A few bed-wetting children are troubled 
with incontinence during the day as well. 
There is a constant leakage, the clothing 
being wet the greater part of the time. The 



Care of the Genitals 287 

management of these cases, however, differs 
in no respect from that advised for those first 
mentioned, except in the matter of medica- 
tion, which can only be carried out by a 
physician. 

CARE OF THE GENITALS 

PAINFUL MICTURITION, CIRCUMCISION 

In girls very little care of the genitals is 
required other than cleanliness. The parts 
should be washed in boiled water and Castile 
soap once a day. Sponges should not be 
used. Soft old linen is far better, and after 
once using it should be burned. A sponge 
is never clean after it has once been used, 
and should have no place in the nursery 
outfit. A nurse should never begin the 
baby's bath until she has thoroughly cleansed 
her own hands with soap and hot water. 
After cleansing, the parts should be dusted 
thoroughly with the following powder: bo- 
racic acid ten grains, powdered starch and 
oxide of zinc each one-half ounce. 

With boys more attention is required. 
The normal condition, a free foreskin, non- 



288 Care of the Genitals 

adherent to the glans penis, is necessary 
for his comfort and health. It should be 
stripped back once a day and the parts 
washed very gently with Castile soap and 
warm water, dried with absorbent cotton, 
and a bit of vaseline applied. In the ma- 
jority of boys the foreskin at birth is tightly 
adherent to the glans, with only a pin-hole 
opening. Such a condition is one of much 
annoyance to the child. Secretions which 
act as a foreign body form under the foreskin, 
producing no little irritation, drawing the 
child's attention to the parts, and thus often 
leading directly to the habit of masturbation. 
Inflammation of the foreskin and urethra 
not infrequently follows this condition. As 
a result, urination is painful and the urine 
is retained until the child cannot pass it. 
I have known children for this reason to 
hold their urine for over twenty-four hours. 
In two cases which came under my obser- 
vation, pus formed under the foreskin, neces- 
sitating immediate operation. In two boys 
aged about two years, repeated convulsions 
occurred, for which no reason could be 
assigned other than the irritation caused 
by the tightly adherent foreskin and the 






Retention of Urine 289 

retained secretions. They were circum- 
cised, and have been perfectly well during 
the two years which have intervened. Bed- 
wetting is often a direct outcome of this 
trouble. 

Four out of five of the boys who come 
under my care need circumcision. This 
does not mean that four out of five are cir- 
cumcised, as family objections are often hard 
to overcome, even where the physician is 
convinced that such a measure would be 
beneficial. In a very few cases, stretching 
and retracting the foreskin may answer every 
purpose. But such cases are rarely attended 
to properly afterward; no matter how care- 
ful the instructions given, the adhesions are 
allowed to re-form, and in a short time all 
the annoying symptoms return. When a 
child is properly circumcised he is relieved 
for all time. 

RETENTION OF URINE 

This condition often greatly alarms 
mothers. In girls, the most frequent cause 
is pain due to the inflammation of the ure- 
thral orifice and the adjoining parts, which 



290 Retention of Urine 

may have been caused either by excessive 
acidity of the urine, or by vaginitis. Re- 
tention sometimes results from taking cold ; 
high fever is sometimes a cause, and, in 
some instances, no cause can be discovered. 
In boys the retention may be due to ure- 
thral irritation produced by excessive acidity 
of the urine; far more frequently, however, 
the trouble is caused by an inflammation 
of the foreskin, which is often swollen to 
three or four times its normal size. In these 
cases the orifice of the urethra will usually 
be found red and swollen. In either sex, 
if there is retention of the urine for over 
sixteen hours, place the child in a tub of 
warm water at a temperature of no° F., 
and often urination will follow immediately. 
Another useful method of treatment con- 
sists in the application to the parts of cloths 
wrung out of hot water. Perhaps the best 
results are obtained by the use of an enema 
of a normal salt solution, — a teaspoonful of 
salt to a pint of water, — at a temperature 
of no° F. ; at least a pint should be used for 
this purpose and the child allowed to retain 
it if he will. This treatment rarely fails. 
If it does, the doctor must use the catheter. 



Nose-Bleed 291 

The swelling of the parts in boys is best 
reduced by a wet dressing of a saturated 
solution of boracic acid, which is applied 
on old linen wrapped around the parts and 
changed every half-hour. In girls a simple 
pad composed of several layers of old linen 
should be saturated with the boracic acid 
solution and similarly applied, the dressing 
being changed every hour, and the parts 
gently bathed with the solution. 

NOSE-BLEED 

Nose-bleed may result from a fall or blow, 
or from any direct injury to the nose. In 
most instances, however, it occurs inde- 
pendently of injury. Adenoids are fre- 
quently a cause of nose-bleed. Small ulcers 
often form on the nasal septum of delicate, 
poorly-nourished children, and give rise to 
most obstinate hemorrhage. Habitual and 
severe nose-bleed, particularly from one 
nostril, is usually due to this cause. What- 
ever may be the cause of the hemorrhage 
the immediate management must be the 
same. The child should sit erect and the 
nose be firmly compressed for twenty min- 



292 Worms 

utes between the thumb and finger. The 
tips of the thumb and finger should touch 
the lower portion of the nasal bones. The 
application of ice is also beneficial; a small 
piece of ice being wrapped in a handkerchief 
and held against the nostril from which the 
blood is flowing. After the hemorrhage has 
ceased, continue the application of ice-cloths 
for one-half hour and watch the child so as 
to prevent his blowing the nose. If the 
hemorrhage is severe, or if slight hemor- 
rhages are repeated, a physician must be 
consulted. 

WORMS 

There are three varieties of worms 
commonly met with in children: the round- 
worm, the thread-worm, and the tape- 
worm. 

Round-worms occur most frequently in 
children from two to ten years of age, 
although no age is exempt. When a child 
picks its nose, grinds its teeth at night, sleeps 
poorly, has a coated tongue, and an indiffer- 
ent appetite, it is supposed by the older 
members of the family to have "worms." 



Worms 293 

These symptoms may indicate the round- 
worms, but they far more frequently indicate 
a too close acquaintance with gingerbread 
and jam and other cupboard, between-meal 
indulgences. Frequent attacks of colic, 
constipation, alternating with diarrhoea, and 
convulsions are, in my judgment, the most 
reliable symptoms of round-worms. The 
only positive means of diagnosis, however, 
is the discovery of the worm itself, or the 
presence of the eggs in the stools. The 
round-worm resembles the common earth- 
worm. It is usually from five to nine inches 
in length .and inhabits the small intestine. 
Round-worms are seldom seen among city 
children ; in the country, however, they occur 
with much greater frequency. 

Thread-worms inhabit the lower portion of 
the large intestine, and in appearance are 
like pieces of white thread. They are usually 
from one-quarter to one-half inch in length. 
They are very frequently seen among the 
children of the tenements. Occasionally 
they occur in children of the better classes. 

The chief symptom of these worms is an 
itching or irritation about the anus. The 
child is restless and sleeps poorly. In girls 



294 Worms 

there may be a vaginal discharge due to the 
irritation caused by the worms, which have 
migrated to these parts. Frequently the 
only symptoms of discomfort will be mani- 
fested when the child is put to bed. He 
will then complain of a biting, burning 
sensation in the rectum. In some, the 
rectal irritation is so great as to cause very 
pronounced nervous symptoms. 

Some years ago I treated a six-year- 
old girl for involuntary movement of the 
arm and shoulders somewhat resembling 
St. Vitus's dance. The trouble disappeared 
after several weeks' treatment for the thread- 
worms which were present in large numbers. 
I have seen many cases of prolapse of the 
bowel due to the straining which was caused 
by the irritant action of the worms. In both 
sexes they may be a cause of bed-wetting 
and in girls are not an infrequent cause of 
masturbation. In some instances after 
treatment the worms will be passed in great 
numbers in the stools, and may sometimes 
be seen adhering to the skin of the parts. 

Tape-worms in children are very rarely 
seen in this country. I have seen but eight 
cases among many thousands of children 



Cuts, Bruises, and Sprains 295 

treated during the past seventeen years. 
The presence of the tape-worm is indi- 
cated by various indefinite manifestations. 
Constipation alternating with diarrhoea are 
prominent symptoms. The child is often 
ravenously hungry. A positive diagnosis 
can be made only after the discharge of 
segments of the worm, which appear like 
short pieces of narrow white tape linked 
together. 

The diagnosis and treatment of worms 
in the children of the household appear to 
be a jealously guarded function of the good 
grandmother. Young mothers, however, will 
do well to have the family physician usurp 
this prerogative. 

CUTS, BRUISES, AND SPRAINS 

Apparently every child must have his 
share of cuts and bruises. In case of ,a cut 
with considerable hemorrhage, pressure to 
the injured parts with cloths saturated with 
cold water will aid in checking the hemor- 
rhage; later, a wet dressing of a saturated 
solution of boracic acid may be applied on 
clean muslin or clean old linen. 



296 Excitement 

If there is a bruise with much swelling to 
be treated, the wet dressing with the boracic 
acid solution will relieve the condition. The 
dressing may be continued for two or three 
hours if required, the bandages being fre- 
quently saturated with the solution in order 
to keep them wet until the doctor arrives. 

A sprain may be treated in a similar man- 
ner. The wet bandages should be bound 
around the injured joint, which, if a lower 
extremity is involved, is kept on a level with 
the body. Severe sprains, cuts, and bruises 
require medical attention at the earliest 
possible moment. 

EXCITEMENT 

A baby should not be subjected to excite- 
ment or its equivalent — too active entertain- 
ment. The nervous system of an infant is 
in such an undeveloped state that what 
would be a decided tax upon it cannot be 
appreciated by adults, who are often appar- 
ently insensible of the fact that children are 
different from themselves. 

The first child in a well-to-do family is 
usually the greatest sufferer from superfluous 



Kissing 297 

attention, — being a source of unending ad- 
miration on the part of the family and friends. 
He is often present very early in life at 
all important functions. Christmas, Thanks- 
giving, birthday celebrations, and afternoon 
teas find him the centre of attraction. He 
is handed from one guest to another and is 
tossed upon various angular knees. He 
is kissed by lips which dare touch only 
those who cannot protect themselves. He is 
talked to with a very loud voice in a very 
silly manner and grimaces horrible to witness 
are made at him. I have witnessed such 
scenes, and have treated exhausted infants 
who required medical attention after the 
seance was over. I have, indeed, seen in- 
fants thus brought to the verge of collapse. 
One child of eleven months had convulsions 
which were indirectly due to fatigue incident 
to a Thanksgiving celebration. 

KISSING 

Such a topic is not to be considered out 
of place in a work of this nature; in taking 
up the child's management in all its details, 
it is my belief that a few remarks on this 



298 Kissing 

subject are perfectly in order. Every detail 
of the child's daily life should be under the 
oversight of the physician, and if he is to do 
his full duty, he must give a certain amount 
of voluntary, unsought advice. A custom 
concerning which he will not be consulted 
is the matter of that most unhygienic 
practice of kissing. 

A child should never be kissed on the 
mouth, and this is a standing order with all 
my patients. I have known, in my own 
private practice, of instances where tuber- 
culosis, diphtheria, and syphilis have been 
communicated from the diseased adult to 
the innocent child by this disgusting prac- 
tice. Neither should the child's hands or 
fingers be kissed, as the hands and fingers 
of the majority of babies are in their mouths 
many times an hour. If baby is the first 
one that has graced the household, and must 
be kissed, this can be accomplished with the 
least damage if the kiss is implanted on 
the head or forehead. The parents must 
make the rule, and they must set the exam- 
ple by adhering to it themselves. 

Among my patients, a nurse who is known 
to have kissed the child is punished by dis- 



Sleep 299 

missal. Because an adult is apparently well 
is no excuse for this indulgence. Healthy 
adults frequently have in their mouths the 
germs of tuberculosis, of diphtheria, and of 
other diseases, and never suffer from their 
presence because they are strong adults with 
vigorous mucous membranes which do not 
furnish as favorable a soil for the growth 
and development of pathogenic bacteria as 
do the more delicate mucous membranes 
of the young. It is criminal, therefore, to 
subject the child to such dangers. Scarlet 
fever, measles, and whooping-cough are all 
most readily transmitted at the beginning 
of an attack through the close contact re- 
quired by a kiss. 

Kissing should not be allowed among 
children. Little girls are very prone to 
follow the customs of their mothers, whether 
good or bad: hence, the necessity of advice 
in this direction will be impressed upon the 
parents if they will observe the interchange 
of bacteria which takes place on the sailing 
or arrival of any of our large ocean steamers ! 

SLEEP 

The infant that sleeps well is almost always 



300 Sleep 

a normal, well-fed baby. Irritability and 
sleeplessness are associated with indigestion 
more frequently than with any other disorder. 
During the first few days of life the sleep, 
in normal conditions, is almost unbroken, 
except when the infant is fed. During the 
first month the infant sleeps about twenty- 
two hours out of every twenty- four; during 
the second and third months, from twenty 
to twenty-two hours. At the sixth month 
the child should sleep from 6 p.m. to 6 a.m. 
without interruption other than for feeding 
or nursing, which need cause very little 
disturbance. At thist age there should be 
a two-hour nap during the morning and a 
two-hour nap in the afternoon, although it 
is not well to have the baby sleep after three 
o'clock in the afternoon. The twelve-hour 
night rest should be continued until the child 
is six years of age. The day naps will grad- 
ually be shortened by the child. At one 
year of age, one hour in the morning and 
two hours in the afternoon suffice. From 
the eighteenth month to the second year, the 
morning nap is given up. Afternoon rest 
for at least one and one-half hours should 
be continued until the child is six years of 



Sleep 301 

age, and longer if he is inclined to be delicate. 
Regular sleep is largely a matter of habit, and 
if the infant is started right, with suitable 
feedings given at definite times, followed by 
the proper period of sleep, but little trouble 
will be experienced with sleeplessness. When 
sleep is disturbed and broken, it means bad 
habits, unsuitable food, minor forms of indi- 
gestion, or positive illness of some kind. 
Sleep is important for purposes of growth 
not only in early infancy but throughout 
childhood. Not a few infants form habits 
of sleeping in the daytime and being wakeful 
at night. This is best remedied by keeping 
the baby awake when he should be, during 
the day, by entertainment and by keeping 
him in a well-lighted room. I am sure that 
the satisfactory results I have had the good 
fortune to achieve in the treatment of sec- 
ondary malnutrition and anemia have been 
due in part to my insistence that the child 
sleep in a quiet, darkened room for two hours 
after the noonday meal. The energy ex- 
pended in twelve hours by an active child 
is incalculable, and when a portion of this 
energy is reserved and the body fortified 
by rest and sleep during the middle of the 



302 Crying 

day, it means a greatly diminished daily 
expenditure of strength units. 

CRYING 

It is well for the young infant to cry a 
little every day. Muscular movements in- 
volving a greater part of the body accompany 
the act of crying and furnish exercise. Peri- 
stalsis is increased, as is often evidenced by 
a movement of the bowels occurring at the 
time, particularly when there is diarrhoea. 
In crying, deep breathing is necessary, the 
lungs are expanded, and the blood oxygen- 
ated. The well baby cries when frightened, 
or uncomfortable from hunger, soiled nap- 
kins, or inflamed buttocks. He cries from 
pain, from heat, from cold, from unsuitable 
clothing, and during difficult evacuation of 
the bow^els. He also cries when displeased 
or angry. Authors are prone to refer to the 
diagnostic value of an infant's cry. It is 
my belief that characteristic cries are not 
to be depended upon sufficiently to give 
them a differential diagnostic dignity. Chil- 
dren slightly but painfully ill may cry in- 
cessantly for an hour or two. Thus, with 



Cleanliness 303 

intestinal colic, where the cry is loud and 
continuous until the child is relieved or until 
he falls asleep from exhaustion. Earache 
is not an infrequent cause. The habitual 
criers, the restless and vigorous crying, 
whining infants, are uncomfortable. With 
very few exceptions the trouble will be found 
in the intestinal tract. The well-trained, 
normal child, whose nourishment is suitable, 
is seldom troublesome. When well, all ba- 
bies are naturally good-natured and happy 
in their own way. Badly managed, spoiled 
infants often cry vigorously when left alone. 
When attention is given them, when they 
are taken up and talked to, the crying ceases. 
This readily tells us that pain or discomfort 
was not an element in causing the cry. In 
these infants, discipline, not medication, is 
needed. The management of the habitual 
crier involves the relief of the condition 
which causes the discomfort, or the most 
rigid discipline. 

CLEANLINESS 

Much has been said and written regarding 
the necessity of cleanliness so far as the child 



304 Cold Hands and Feet 

is concerned; but not only should the nurse 
and mother see that the baby is clean ; they 
must be clean themselves. Immediately 
after every attention to the napkin the hands 
should be washed with hot water and soap 
and a stiff brush. This cleansing process 
must be repeated before the preparation of 
the food or any manipulation of the feeding 
apparatus. 

The child's attendants should not have 
decayed or neglected teeth. The tooth- 
brush should be an important article in the 
outfit of every nurse. She should take a 
tub-bath or sponge-bath daily. The hands 
and finger-nails of many nursery-maids will 
bear watching. 

COLD HANDS AND FEET 

The hands and feet of the infant should 
never be cold to the touch. This is a cause 
of much of his discomfort and restlessness. 
A very young child with poor circulation 
will be made much more comfortable by 
placing a hot-water bag at his feet. Bottles 
filled with warm water and wrapped in 
flannel will keep the upper extremities warm. 



Foreign Bodies Swallowed 305 

In using the hot-water bags and bottles be 
sure that the water is not too hot. Severe 
burning accidents have resulted from care- 
lessness in this particular. 

An excellent means of keeping premature 
or delicate babies warm is in the use of the 
"Electrotherm" (Fig. 12). These small 
heaters are attached to an electric fixture, 
like a drop-light. A convenient size is from 
ten to fifteen inches. It is placed between 
two or three thicknesses of blankets, upon 
which the infant lies in its basket or crib. 
The degree of heat can be regulated accord- 
ing to the amount of electricity turned on. 

FOREIGN BODIES SWALLOWED 

The child's stomach is a frequent recep- 
tacle for objects for which it was never 
intended. Pins, buttons, safety-pins, small 
pieces of chalk, pencils, etc., often find their 
way into the stomach of the "runabout" 
child. I knew one child to swallow an open 
safety-pin, and another to swallow a stick- 
pin, the head of which was a small four-leafed 
clover. Both children passed the pins with- 
out the least harm resulting. In order that 



306 Foreign Bodies in Ear and Nose 

the object swallowed may not injure the 
child, give starchy substances in large 
amount: oatmeal, potatoes, corn-meal mush, 
— substances which in the intestines form 
a semi-solid mass in which the object swal- 
lowed may become imbedded and carried 
forward. These cases should never be given 
castor-oil or any other laxative. 

FOREIGN BODIES IN THE EAR AND 
NOSE 

This subject is brought to the attention of 
mothers to warn them against any attempt 
at the removal of foreign bodies from the 
nose or ears of one of their children. The 
means often thus employed, such as hair- 
pins, button-hooks, etc., should never be 
used, as they are liable to do much harm. 
I have often removed shoe-buttons, peas, 
beans, pieces of coal, and pebbles from the 
nose, and have had trouble only with those 
cases in which some member of the family 
had attempted the removal with the result 
of forcing the foreign body farther into the 
cavity. When the foreign body is in the 
nose, the child, if old enough, can sometimes 



Flies and Mosquitoes 307 

remove the obstacle by pressing upon the 
unobstructed nostril while he vigorously 
blows the nose. When this does not succeed 
the child should be taken to a physician. 

DANGERS FROM FLIES AND MOS- 
QUITOES 

The windows of the nursery should be 
screened so that flies and mosquitoes can- 
not enter. When out of doors the very 
young child should be protected by mos- 
quito-netting. Mosquitoes severely poison 
many children, and are of especial danger 
in that one variety is capable of inoculat- 
ing the child with malaria, the Plasmodium 
malaria: being deposited along with the other 
poison. 

Flies, in addition to disturbing sleep, are 
a source of much danger which is but little 
appreciated. The fly enters the nursery and 
alights on the nipple of the nursing-bottle. 
This may take place while the child is resting 
for a second or two during his meal, as flies 
are very fond of the sweet milk which may 
adhere to the nipple; or the fly may alight 
upon the child's bread, or the prepared cereal, 



308 The Doctor 

or any article of food, particularly if there 
is a sweet element in it. The last place the 
fly rested before reaching the nursery we 
never know. It may have been on animal 
excrement, or tubercular sputum, or the 
infectious discharges of a typhoid-fever 
patient. In this way the flies' feet and legs 
are the means of transporting the germs of 
typhoid fever or diphtheria. Tuberculosis is 
unquestionably transferred in this way very 
frequently, minor ailments with still greater 
frequency. Flies are a source of danger 
in the house, and should be driven out or 
destroyed. 

WHEN TO SEND FOR THE DOCTOR 

This question is easily answered. Send 
for the doctor when there are any indica- 
tions of illness in the child which the mother 
does not understand. It is better to be 
overcautious in this respect than to join the 
great number of mothers who are never free 
from the bitter, life-long regret, "The child 
might have been saved had he been treated 
in time." I know such mothers. 

There are two conditions in which the 



Patent Medicines 309 

mother must not trust herself for a moment. 
These are summer diarrhoea and sore throat. 
"Only a summer diarrhoea,' ' and "only a 
sore throat,' ' and "only a teething diarr- 
hoea," have sacrificed the lives of hundreds 
of infants. 

Diphtheria is a very prevalent disease, 
and the successful treatment of it requires 
that the child be seen by the physician at 
the earliest possible moment. So, also, with 
summer diarrhoea. I have seen infants die 
in twelve hours with the disease. Calling 
a doctor early is a means not only of safety, 
but of economy. In the correction of slight 
ailments, grave ones are avoided. 

PATENT MEDICINES 

Patent medicines should form no part 
of the nursery outfit. The mother's home 
remedies should all be approved by a physi- 
cian. Cough mixtures and soothing syrups, 
the advantages of which are so faithfully 
portrayed in the popular magazines and 
religious periodicals, are often very harmful. 
Most of them contain alcohol, opium, or 
morphine. Time and again I have seen 



3 io Summer Resorts 

children drugged to the point of stupor by 
these remedies. 

SUMMER RESORTS 

Where to take the child for the summer 
is a vexed question which arises once a year 
in many households. Several years of obser- 
vation of a great many children who have 
spent the summer out of town have led me 
to the following conclusions: 

i. The most desirable summer outing: 
the first half of the season at the seashore, 
the remainder inland, preferably in the 
mountains. 

2. The next in order of desirability: 
inland, preferably the mountains for the 
entire summer. 

3. The least desirable: the seashore for 
the entire summer. 

I do not wish it understood that many 
children will not do well at the seashore if 
kept there the entire summer; some, indeed, 
improve wonderfully; but among my own 
patients I have been repeatedly impressed 
with the disadvantages of a prolonged outing 
by the sea. The seashore children, as a rule, 



Summer Resorts 3 1 1 

do not return to the city in the fall with the 
vigor, appetite, and general robustness which 
characterize those who return from the 
mountains. I refer only to New York chil- 
dren, whose home is a seaport, and who 
thrive best when given the advantage of 
a complete change to the dry, invigorating 
air of the mountains. Children with catar- 
rhal tendencies, adenoids, bronchitis, and 
rheumatism, and those convalescent from 
pneumonia, should not go to the seashore. 

In selecting an inland resort, the moun- 
tains, by which we understand an elevation 
of from fifteen hundred to two thousand 
feet, are not always necessary. The place 
selected, however, should have an elevation 
of at least six hundred feet, and should not 
be within sixty miles of the coast. Children 
who are subject to rheumatism and bron- 
chitis do best on a sandy soil, in a dry cli- 
mate, with the sleeping rooms above the 
ground floor. 

Another point to be considered in this 
connection is the kitchen facilities which 
will be provided for the preparation of the 
child's food. As a rule, the larger hotels 
refuse the right of way to the kitchen; or, 



312 Drug-Giving 

if they do not, it is at the expense of many 
material attentions to the chef. I find that 
mothers are given much more latitude as 
to these matters in the smaller hotels and 
boarding-houses. The proper preparation 
of a child's food in the cramped quarters 
of the sleeping apartment is not impossible, 
but it is very difficult. 

Before selecting a summer home, the 
drainage, the milk, and the water supply 
must be considered. If the parents possess 
the means, a cottage should be rented, which 
will insure them all the comforts of home. 
Country well water or spring water should 
always be boiled before using. 

DRUG-GIVING 

Drugs are of service only in the hands of 
those who are trained in their use. Mothers 
often acquire the habit of treating their chil- 
dren. Self-prescribing is greatly overdone 
in this country among all classes. Many 
people know just enough about medicines 
to be dangerous members of society. The 
proprietary cough mixtures, soothing syrups, 
teas, carminatives, etc., are often injurious. 



The Daily Outing 313 

They usually contain opium,— a drug which 
a mother should never think of giving her 
baby on her own responsibility. It is not 
at all uncommon in hospital work to have 
children admitted in an opium stupor which 
resists all treatment for hours. 

While the habit of promiscuous drug- 
giving is to be condemned, the mother is 
not supposed to remain inactive while await- 
ing the arrival of the physician ; a preliminary 
dose of castor-oil in diarrhoea, or syrup of 
ipecac in croup, or rhubarb and soda when 
there is a furred tongue in indigestion, will 
always be in order. The mother may have 
her home remedies, but the physician must 
instruct her in their use. 

THE DAILY OUTING 

The baby should not go out in stormy 
weather. If under one year of age he should 
not go out if the temperature is below 20 
F. During the midday heat of summer the 
baby is better off in the largest and coolest 
room in the house or on a shady ver- 
anda. On very windy days the outing 
should be postponed. When the snow is 



314 Indoor Airing 

melting in large quantities the baby is better 
off indoors. 

INDOOR AIRING 

For this purpose the child is dressed as 
for the daily outing. All the windows of 
the nursery or some other large room are 
opened, on one side of the room only. The 
doors should be closed, so that currents of 
air are avoided. The child is placed in his 
carriage, suitably covered, and wheeled about 
the room for an hour or two. This, if done 
twice daily, answers almost as well as the 
actual outing. 

This method will be found very useful in 
"winter babies' ' — those born during the late 
fall or winter months. The indoor airing 
may be given for a week or more, before he 
is taken out. By this means the child is 
gradually accustomed to a change of the 
temperature from that of the average living- 
room to that of out-of-doors, and will not 
be harmed when he is finally taken out. 
After an illness, it will afford an earlier means 
of returning to the daily outing. This 
method of giving a child fresh air will be 



Children's Parties 315 

found useful with very delicate children, 
who, by reason of their condition, may be 
unable to go out during the winter months 
for several weeks at a time. There are, 
however, but few days during the winter 
that are too cold or too stormy for the indoor 
airing. 

CHILDREN'S PARTIES 

Parties for children, under the sixth year 
of age are to be discouraged. The import- 
ant features of a child's party are entertain- 
ment and the " banquet.' ' There are two 
features of child life that are important to 
guard against — excitement and injudicious 
feeding. Exciting play and unusual articles 
of food at an unusual time appear to be a 
necessary part of a so-called children's party. 
The bringing together of children of tender 
age is further to be discouraged because it 
increases their liability to contract the con- 
tagious diseases from which every child 
should be protected to the full extent of 
our ability. 

Not long since a patient, — a little boy four 
years old, — invited fourteen little boys and 



316 Baskets for Early Exercise 

girls of corresponding ages to celebrate his 
birthday. The little host was more gen- 
erous than was his wont ; he gave more than 
the banquet! The night of the birthday 
party he was very uncomfortable. The 
following day he developed chicken-pox. In 
due course of time twelve of the fourteen 
little guests came down with chicken-pox. 
They were fortunate that it was only chicken- 
pox; it might have been scarlet fever or 
diphtheria. 

I regret that I have not kept a record 
of the acute illnesses that have followed 
children's parties under my immediate ob- 
servation. Acute indigestion, diarrhoea, con- 
vulsions, and all of the contagious diseases 
of childhood would be found in generous 
numbers in such a record. 

BASKETS FOR EARLY EXERCISE 

It is a great mistake to have the infant 
constantly in arms. The first baby suffers 
more in this respect than later children. 
When the child is held, there is always a 
tendency to make him sit on the arm or knee 
without proper support, or to toss about or 
handle him regardless of consequences. The 



Baskets for Early Exercise 317 

bones and ligaments of the spinal column 
are not sufficiently developed to bear the 
weight of the heavy head and trunk, and, 




FIG 19. BASKET FOR EARLY EXERCISE 

as a result, as the child grows older, spinal 
curvature and other deformities not infre- 
quently follow. By urging him to stand 
on the lap the legs are used more than is 
advisable, and we find bow-legs or knock- 
knees very prevalent. 

A large clothes-basket, in which a thick 
blanket has been placed (see Fig. 19) furnishes 
a safe and satisfactory playground. For 
the first few months the child will rest on 
his back and amuse himself in his own pecu- 
liar way. When he can sit up, supported 
by a pillow at his back, the basket gives him 



3*8 Night Terrors 

plenty of room for toys and other baby re- 
quirements. In it the baby is practically 
safe. He is not apt to be injured by young 
members of the family in rough play. He 
cannot crawl to the stove to be burned, and 
is in no danger of rolling down-stairs. When 
he can stand and begins to walk, the basket 
period is at an end. 

NIGHT TERRORS 

The child awakens suddenly from sleep, 
cries out with fear, and begs to be protected 
from men and animals, which he imagines 
are trying to injure him. In some cases 
the nurse and immediate relatives of the 
family will not be recognized. The seizures 
may occur quite regularly every night until 
the cause is removed. Other children may 
have but one or two attacks in a week. The 
seizures are usually due to a disordered diges- 
tive tract in a nervous child. Adenoids and 
enlarged tonsils are considered by some to 
act as a predisposing cause. Anxiety re- 
garding school duties, or overwork at school 
may help to bring on an attack ; worms may 
also be a cause. My cases have all been due 
either to acute or chronic digestive disturb- 



Scales for Weighing 319 

ances in nervous children. A boy patient 
twelve years of age has had two attacks 
every year, with one exception, since he was 
six years old. These attacks always occur 
on the nights after Christmas and his birth- 
day, after indulgence in all sorts of unsuitable 
articles of food. 

During the attack the child must be treated 
with gentleness; scolding makes matters 
worse. If possible, he should be induced to 
go to sleep ; oftentimes a change to the bed 
of the nurse or mother for the remainder of 
the night will be all that is necessary; or a 
light may be left burning in the room. The 
attacks may usually be prevented by a suit- 
able diet. The evening meal should be very 
light — a cereal with milk and a little stewed 
fruit is sufficient. This light supper has 
relieved several of my patients of habitual 
night terrors. Constipation is often an im- 
portant factor, and when present requires 
treatment before relief is to be expected. 

SCALES FOR WEIGHING 

A scale for weighing the baby is a very 
necessary adjunct to the nursery furnishings. 



320 Scales for Weighing 

There are, on the market, several varieties 
of scales for weighing the baby, which are 
unknown as "baby scales." The usual con- 
struction is that of a basket, into which the 
baby is placed, supported by a rod which 
rests upon a spring. A needle indicates on 
a dial the weight of the child. The use of 




FIG. 20. SCOOP AND PLATFORM SCALES FOR WEIGHING 

these scales is not to be advised. They get 
out of order easily, are expensive, and with 
a vigorous, kicking, crying baby, the rapid 
oscillations of the needle often prevent the 
weight being read with any degree of accu- 
racy. Further, their weight capacity is but 



The Exercise Pen 321 

twenty pounds. When the child's weight 
reaches this figure, it necessitates the pur- 
chase of other scales. The scoop and plat- 
form scales used by grocers (see Fig. 20) 
answer the purpose far better than any 
others. They can be bought for about 
$3.50,* do not get out of order, and weigh 
correctly from one-half ounce to two hun- 
dred and eighty pounds. The infant rests 
on his back in the scoop during the weigh- 
ing process. Older children stand on the 
platform. 

THE EXERCISE PEN 

In a previous chapter, in speaking of cold 
and how children were exposed to influences 
which might bring about what is known as a 
"cold," the custom of allowing a child to sit 
on the floor is referred to. 

To keep a child from eight to twenty-four 
months of age off the floor during the winter 
months, and thereby prevent his taking cold, 
is a very difficult matter. In fact, with 
active children who are learning to walk, 

1 Metropolitan Hardware Co., Church and Vesey Sts., 
N. Y. C. 



The Exercise Pen 323 

or who have just learned to walk, it is prac- 
tically impossible. During this season of the 
year there is always a current of cold air near 
the floor, and allowing the child to creep on 
the floor in winter, even if it is protected by 
rug and pillows, is one of the surest ways of 
taking cold. If he is allowed to walk on the 
floor he is very sure to sit in a very few 
minutes. If he is not allowed to creep and 
walk about at will he will not get the proper 
exercise, and will show faulty development ; 
for such cases I have found the exercise pen 
(see Pig. 21) of immense service. After being 
dressed, washed, and fed, the infant is placed 
in the pen on a rug or quilt, toys are given 
him, and the door closed. He can now roam 
about at will, stand up, sit down, roll, creep, 
or walk without danger of physical harm 
from rolling down-stairs, being burned, or 
being stepped on. He is thus given an 
opportunity for active exercise without a 
possible chance of injury. 

A young mother of two children will take 
her "pen" into the country in the summer 
and place it in the shade for use while the 
dew is on the grass. In case the nursery is 
small it can be made so as to fit over the 



324 Food Formulas 

nurse's bed and consequently does not re- 
quire any additional space. In a large 
nursery it can be placed permanently in 
one corner of the room, thus avoiding the 
trouble of putting it up and taking it down. 
The pen can be made of any size, — 4 x 6 ft. 
is probably the most convenient, although 
several made 4x4 ft. are in use. It is so con- 
structed as to be taken apart and put to- 
gether in a few moments, iron tenon hooks 
and iron mortices being used to hold the parts 
together. The floor may be made of any 
thin material. One-quarter inch pine boards 
nailed together so that the floor will be com- 
posed of two thicknesses, or papier-mache 
supported by narrow strips of board, may 
be used. The floor is supported by strips 
of board about one-half by two inches, which 
are fastened to the inner side of the end- 
pieces. 

FOOD FORMULAS 

Beef -juice. — Take a round steak, cut into 
pieces the size of a horse-chestnut, place in 
a buttered pan in a hot oven, and bake for 
fifteen minutes; remove from the pan and 



Food Formulas 325 

press out the blood with a lemon-squeezer 
or meat-press. Or, broil round steak very 
rare, cut into small pieces, place in a lemon- 
squeezer or meat-press, and press out the 
blood ; add a little salt. 

Beef, mutton, and chicken broth. — Take one 
pound of meat free from fat, cook for three 
hours in one quart of water, adding water 
from time to time, so that when the cooking 
is completed there will be one pint of broth. 
When the broth is cool, remove the fat, 
strain and add salt. 

Scraped beef. — Broil round steak slightly 
over a brisk fire. Split the steak and scrape 
out pulp, using a dull knife. 

Egg-water.— -The white of one egg, thor- 
oughly beaten in one pint of cold boiled 
water, strain, add a pinch of salt. 

Oatmeal jelly. — Oatmeal, four ounces; 
water, one pint; boil for three hours in a 
double boiler, water being added, so that 
when the cooking is completed a thin paste 
will be formed. This while hot is forced 
through a colander to remove the coarser 
particles. When cold, a semi-solid mass will 
be formed. 

Wheat jelly and barley jelly. — Wheat jelly 



326 Food Formulas 

and barley jelly are made in the same way 
as oatmeal jelly, using cracked wheat or 
barley grains. 

Barley-water. — Robinson's barley flour or 
Cereo Co.'s barley flour, one rounded table- 
spoonful; water, one pint; boil thirty 
minutes, strain, add water to make one pint. 

Rice-water. — Rice, one tablespoonful ; 
water, one pint; boil three hours, adding 
water from time to time, so that there is 
one pint of rice-water at the end of three 
hours. 

Dextrinized barley-water. — Robinson's bar- 
ley flour or Cereo barley flour, three table- 
spoonfuls; water, one pint; boil twenty 
minutes, add water to make a pint. When 
lukewarm (ioo° F.) add one teaspoonful of 
Cereo, strain; this changes the starch into 
dextrinized maltose. 

Oatmeal-water. — Oatmeal, one tablespoon- 
ful; water, one pint; cook three hours and 
add water to make one pint. 

Imperial granum-water. — Imperial granum, 
one tablespoonful; water, one pint; cook 
thirty minutes and add water to make one 
pint. 

Whey. — Put one pint of fresh milk into a 



Food Formulas 327 

saucepan and heat it lukewarm, not over 
ioo° F. ; then add two (2) teaspoonfuls of 
Fairchild's essence of pepsin and stir just 
enough to mix. Let it stand until firmly 
jellied, then beat with a fork until it is finely 
divided, strain, and the whey, the liquid 
part, is ready for use. 

Junket. — To one pint of fresh milk add 
one tablespoonful of essence of pepsin or a 
junket tablet, and two teaspoonfuls of sugar. 
Allow it to stand over a fire until the tem- 
perature is ioo° F. ; then add vanilla as a 
flavoring and allow it to stand until the curd 
is set, when it should be placed upon ice. 



THE END 



BOOKS FOR THE HOUSEHOLD 



Till the Doctor Comes 






and How to Help Him 



IV 



GEORGEH. HOPE.M.D. 

Xe~ ti::::r_. revised and 
br:ur"-: :: date. :y Mavy J. 

Kydd, :;.d. i6 = , $i.oo. 



ness. The : :".-. is en:ire:y 
:rthy, and should be 
in t t:y home. A feature of 
great value is a tabulation of 
symptoms, whereby various 
more common diseases may 
be detected. 



1 A most admirable trea- 

tise — Jz ' : //' ■; '-. 

" Ought to be in every 
family. " — Ch ristian InUtti- 

s- '''■ -'-"'■ 

" F : r concise and sensible 
advice, we know of no bettei 
book." — Worcester Spy. 



G. P. PUTNAM'S SONS 

New York and London 



" I consider it the best I have seen and shall recommend its use 
in our school." — Kate A. Sanborn, Supt. of Training School for 
Nurses, St. Vincents Hospital. 



Essentials of Dietetics 

In Health and Disease 

A TEXT-BOOK FOR NURSES AND A PRAC= 

TICAL DIETARY GUIDE FOR 

THE HOUSEHOLD 

By AMY ELIZABETH POPE, author, with 
ANNA CAROLINE MAXWELL 

of •• Practical Nursing"; and Instructor in the Presbyterian 
Hospital School ol Nursing 

and 

MARY L. CARPENTER 

Director of Domestic Science of the Public Schools 
Saratoga Springs, N. Y. 

Crown 8vo, Illustrated. $1.00 net 



Essentials of Dietetics is primarily a text-book, intended to 
facilitate the teaching of dietetics in schools of nursing. Its aim 
is to furnish nurses with such information as is indispensable, 
and can be assimilated in the time given to the study of dietetics 
in the nursing-school curriculum. It is also adapted to use as a 
dietary guide for the home. At least one-third of the women 
who enter the larger schools of nursing do so with the desire of 
being prepared to take charge of hospitals or to do settlement 
work, and in both these branches of the nursing profession hardly 
any one thing is more important than knowing how to direct the 
buying, preservation, cooking, and serving of food. To do this 
intelligently it is absolutely necessary to have some knowledge 
of the chemistry of foods, of the special uses of the various food 
principles to the body, of the proportions in which they are con- 
tained in the different foods, and of the effect on them of acids, 
heat, salt, digestive ferments, etc. 



G. P. PUTNAM'S SONS 

NEW YORK LONDON 



" Practical experience speaks from every page of the book — 
this gives it at once its greatest value and its charm , , * not 
an idle word - not a shred of padding is to be found between the 
two covers/' — American Journal of Nursing. 

Practical Nursing 

A Text-Book for Nurses and a Hand-Book for 
all who Care for the Sick 

By ANNA CAROLINE MAXWELL 

Superintendent of the Presbyterian Hospital School of 
Nursing 

— AND — 

AMY ELIZABETH POPE 

Instructor in the Presbyterian Hospital School 
of Nursing 

Illustrated. Crown 8vo. $1-75 net 

(Postage, 12 Cents) 

44 The appearance of this work, the fruit of the conjoined 
labors of Miss Maxwell and Miss Pope, marks a turning-point 
in nursing literature. Up to the present time, the " text- 
book" and "hand-book" of nursing have treated of subjects 
which, while they necessarily and indispensably belong in the 
curriculum of every school for nurses, are yet subjects quite apart 
from practical nursing in the hospital wards or at the bedside of 
the sick, and quite out of place in a text-book of nursing. One 
needs to read the book to appreciate it ; a mere enumeration of 
the subjects gives no hint of the immense amount of care 
taken to quote methods which have been proved by experi- 
ence in many schools to be the means best adapted to 
give good results and at the same time to insure the comfort 
and confidence of the patient." — American Journal of Nursing. 



G. P. PUTNAM'S SONS 
New York London 



Ji Book for Parents and Teachers 

The Century of the Child 

By Ellen Key 

Cr. Svo, with Frontispiece. Net y $1.50 

The Century of the Child has gone through 
more than twenty German editions and has been 
published in several European countries. Since 
Ellen Key severed her connection with the 
champions of women's emancipation twelve 
years ago, by asserting that the salvation of 
women depended upon a nobler conception of 
her natural mission as wife and mother rather 
than upon an enlargement of her sphere, she has 
devoted herself largely to educational questions, 
and her seriousness and sincerity of ethical pur- 
poses have won for her a large and enthusiastic 
following. Some of her ideas are strongly 
revolutionary, but in educational questions she 
shows originality, and her writings have a wide 
appeal among progressive people. In the mat- 
ter of the education of children she is the foe of 
mechanical methods and recommends a large 
liberty in the bringing-up of young people. 

G. P. Putnam's Sons 

New York London 



